[Senate Hearing 114-482]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 114-482

  FIELD HEARING ON EXPLORING THE VETERANS CHOICE PROGRAM PROBLEMS IN 
                                 ALASKA

=======================================================================

                                 HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            AUGUST 25, 2015

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
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                     COMMITTEE ON VETERANS' AFFAIRS

                   Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas                  Richard Blumenthal, Connecticut, 
John Boozman, Arkansas                   Ranking Member
Dean Heller, Nevada                  Patty Murray, Washington
Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota            Sherrod Brown, Ohio
Thom Tillis, North Carolina          Jon Tester, Montana
Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                     Joe Manchin III, West Virginia
                       Tom Bowman, Staff Director
                 John Kruse, Democratic Staff Director
                           
                           
                            
                           C O N T E N T S

                              ----------                              

                            August 25, 2015
                                SENATORS

                                                                   Page
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................     1

                               WITNESSES

Bowen, Verdie, Director, Office of Veterans Affairs, State of 
  Alaska.........................................................     4
    Prepared statement...........................................     7
Joslin, David, Veteran...........................................    14
    Prepared statement...........................................    16
Williams, Susan, Veteran.........................................    17
    Prepared statement...........................................    19
Watts, Walter W., Jr., Commander, Veterans of Foreign Wars, State 
  of Alaska......................................................    20
Shulkin, David J., M.D., Under Secretary for Health, U.S. 
  Department of Veterans Affairs; accompanied by Thomas Lynch, 
  Assistant Deputy Under Secretary for Health Clinical 
  Operations; Larry Carroll, Network Director, VISN 20; and Linda 
  Boyle, Acting Director, Alaska VA Healthcare System............    28
    Prepared statement...........................................    30
Buck, Andrea C., M.D., Chief of Staff, Healthcare Oversight 
  Integration, Office of Inspector General, U.S. Department of 
  Veterans Affairs, accompanied by Sami O'Neill, Director, 
  Seattle, WA, Office of Healthcare Inspections..................    34
    Prepared statement...........................................    37
McIntyre, David, President and Chief Executive 
  Officer, TriWest Healthcare....................................    40
    Prepared statement...........................................    42

                                APPENDIX
                     Public Testimony from Alaskans

Ambasht, Saket, M.D., Pioneer GI Clinic, Anchorage, AK; email 
  submission.....................................................    57
Anonymous Submission; email submission...........................    57
Bacom, Elizabeth, Petersburg, AK; email submission...............    61
Beard, Brian S., US Army, Service-Disabled Veteran, Sterling, AK; 
  email submission...............................................    61
Carlow, Diane, biller, Kenai Peninsula medical office, Kenai, AK; 
  email submission...............................................    52
Carter, Tom, Fairbanks, AK; email submission.....................    63
Farrington, Jerry, Kenai Peninsula, AK; email submission.........    63
Fassler, Jim, Kenai Peninsula, AK; email submission..............    64
Ferraro, Dorothy, Director, Public Relations, South Peninsula 
  Hospital; email submission.....................................    65
Glass, Graham A., M.D., Peak Neurology & Sleep Medicine, LLC, 
  Anchorage, AK; email submission................................    66
Heckert, Donald W., Nikiski, AK; email submission................    67
Heidemann, Emmet, Eagle River, AK; email submission..............    67
Kosterman, Dan J.; email submission..............................    67
Linton, Pat, Executive Director, Seward Community Health Center, 
  Seward, AK; email submission...................................    68
Nicely, John F., Anchorage, AK; email submission.................    69
Pictou, Dana, Veteran and Clinical Social Worker, Fairbanks, AK; 
  email submission...............................................    69
Pound, James, Kenai, AK; email submission........................    70
Proetto, Jay, Haines, AK; email submission.......................    70
Senner, Samuel, Anchorage, AK; statement by phone................    71
Shields, Glenn, Delta Junction, AK; email submission.............    71
Stevenson, Richard L., Wasilla, AK; email submission.............    72
Swain, Aaron, Case Manager, Adult Behavioral Health, Kenai 
  Peninsula, AK; email submission................................    72
Trojan, Jan; email submission....................................    73
Williams, Susan, speaking for a female veteran, Chugiak, AK; 
  email submission...............................................    73
Zumbro, David S., M.D., Alaska Retinal Consultants, Anchorage, 
  AK; email submission...........................................    73

 
  FIELD HEARING ON EXPLORING THE VETERANS CHOICE PROGRAM PROBLEMS IN 
                                 ALASKA

                              ----------                              


                        TUESDAY, AUGUST 25, 2015

                                        U.S. Senate
                             Committee on Veterans' Affairs
                                                    Eagle River, AK
    The Committee met, pursuant to notice, at 5:40 p.m., at The 
Alliance Christian Fellowship Church, 16620 Brooks Loop, Eagle 
River, Alaska, Hon. Dan Sullivan presiding.
    Present: Senator Sullivan.

            OPENING STATEMENT OF HON. DAN SULLIVAN, 
                    U.S. SENATOR FROM ALASKA

    The Chairman. This hearing of the U.S. Senate Veterans' 
Affairs Committee will now come to order.
    We are here for a simple reason: to bring together key 
players responsible for delivering health care and benefits for 
Alaska's veterans so they can fix a problem, a big problem for 
our State, the implementation of the Choice Act, which is 
negatively affecting literally thousands of Alaskan veterans 
and their families.
    That is our stated objective, and I intend to work on this 
issue to make it happen. That is what this hearing is about.
    We have an outstanding panel of witnesses on two panels. 
The key, though, tonight, is that we do not need rhetoric. What 
we need are answers.
    How did we get here? The Choice Act was passed in 2014 
during the last congressional session to respond to the 
scandals and backlogs that were plaguing the VA nationally. It 
is because of its one-size-fits-all design that the 
implementation of the Choice Act in Alaska has been nothing 
less than an unmitigated failure for our veterans.
    Many of Alaska's officials, both military and elected 
officials, saw this crisis of care coming. Let me provide a 
couple letters that indicate that.
    A letter from Senator Murkowski to the VA earlier this year 
where she states, ``I write with great urgency concerning 
changes that appear to be occurring in the Alaska VA Healthcare 
System as a result of the implementation of the Veterans 
Access, Choice and Accountability Act, the Choice Act.''
    Congressman Young wrote to the VA, ``Alaska VA Healthcare 
System is facing serious issues as a result of poor 
implementation of the Choice Act.''
    Governor Walker literally pleaded with the VA in a letter, 
``Please help me prevent the devastating loss of an innovative 
and award-winning program that has improved access to medical 
care for all of Alaska's veterans.''
    In my letter to the chairman of the Senate Veterans' 
Affairs Committee, Sen. Johnny Isakson, asking for the 
authorization to hold this hearing in Alaska, I told the 
chairman of how ``a new national one-size-fits-all policy was 
once again unsuccessful in Alaska.'' I told him of the troubles 
Alaska's veterans had calling for Choice program hotline, how 
TriWest call centers are placing our State's veterans on hold 
until their calls were dropped time and time again. In many 
cases, promises for callbacks never occurred.
    That is unacceptable.
    Equally alarming for our veterans in Alaska in addition to 
the Choice program rollout was the recent report on the Mat-Su 
Community-Based Outpatient Clinic issued by the VA Office of 
the Inspector General. This report, which was requested by 
Senator Murkowski, found that understaffing and larger provider 
workloads contributed to very long wait times for our veterans 
and poor patient care.
    We have two distinguished panels that will testify this 
evening on these issues. I am particularly pleased to have Dr. 
David Shulkin, the Under Secretary for Health in the Veterans 
Administration on our second panel. He is the number 3 ranking 
official in the VA who has come to Alaska. Dr. Shulkin has a 
very distinguished resume, a very distinguished career as a 
doctor, as a medical administrator, and as a hospital 
administrator. He has only been with the VA for 6 weeks. He did 
not cause these problems.
    Nevertheless, when he was up for his confirmation hearing 
and ready to be confirmed, I put a hold on his confirmation 
until I received a personal commitment from Dr. Shulkin to come 
to Alaska, to travel the State with me, to listen to our 
veterans, and to come here ready to work with others to devise 
a plan to fix the problems with the implementation of the 
Choice Act in Alaska. I am proud to say that is what he has 
done. That is what we have done.
    I have spent the last day and one-half with Dr. Shulkin in 
Kenai and in Fairbanks for veteran listening sessions. We were 
at JBER at the VA/DOD Joint Venture Hospital today.
    Several themes have emerged from our meetings, from our 
hearings, from hearing literally hundreds of veterans 
throughout the State of Alaska. These themes are not surprising 
to this panel. The Choice Act is not working. TriWest and the 
VA are not communicating at all. The frustration levels have 
peaked in our State among veterans, among family members. Many 
of Alaska's veterans are going without care, care that they 
have earned. Some are even being saddled with bills in the tens 
of thousands of dollars, with collection agencies on their 
heels even though they have done nothing wrong.
    We are going to change this. This is completely 
unacceptable. I want to thank the hundreds of veterans who 
attended our listening sessions yesterday and all of you who 
are attending this hearing tonight.
    I understand that there are also some who have not been 
able to attend these sessions or will not be testifying 
tonight, so I want to make sure that all Alaskans have the 
opportunity to participate in this official hearing of the U.S. 
Senate Veterans' Affairs Committee. We have set up an email 
address. The email address is 
[email protected]. Any Alaskan can submit 
testimony as part of the official record of this Committee 
hearing, and we will leave the record open for this hearing 
until 5:30 p.m. Alaska time on September 1, 2015.
    The bottom line for what we are trying to do tonight is 
that we are trying to bring Washington, DC, to Alaska. As VA 
Secretary McDonald stated recently, America's veterans have 
lost faith in the VA. The VA needs to restore that faith, 
restore that sacred trust of responsibility we all owe to our 
veterans. It starts with the respect we are showing here 
tonight by having our hearing on Alaska veterans issues not in 
Washington, DC, but here in Alaska, so as many veterans as 
possible can testify and weigh in on these important issues.
    This hearing will be a bit nontraditional. Unlike all 
Washington, DC, hearings where the normal policy of the 
Committee is to have the government witnesses speak on the 
first panel, I felt it was important to flip that tradition and 
have Alaskan veterans and those who are responsible for them to 
testify first.
    As such, our witnesses from the VA and TriWest will be able 
to hear some of the concerns from my fellow Alaskans, hear 
their perspectives, and hopefully be able to address some of 
their concerns when we have our second panel of witnesses.
    Overall, I think many here would agree that part of this 
hearing is not just to find solutions, but to provide 
accountability: congressional oversight and accountability. It 
is accountability for TriWest. It is accountability from the 
VA. It is accountability from Congress. Importantly, though, 
and this is really important for our second panel to 
understand, this accountability is not directed at the Senate 
or the Congress, ultimately. Rather, ultimately, it is directed 
at our veterans. It is directed at what this hearing is all 
about, Alaska's veterans.
    I would respectfully request that all witnesses on the 
first panel and the second panel keep that in mind as you give 
answers to questions and as you deliver your opening 
statements.
    With that, I would like to thank all the witnesses, 
particularly witnesses from out of town, for being here.
    There has been a lot of blame, a lot of finger-pointing. In 
some ways, finding accountability for the mess we are in is 
important. What I really want to do here, what I really think 
is important here, is not to look back, but to look forward and 
work together, all of us, to address what everybody recognizes, 
what I referred to earlier as a five-alarm fire for Alaska's 
veterans. I think Dr. Shulkin and I certainly saw this when we 
heard from dozens if not hundreds of veterans over the last 2 
days throughout the State.
    The goal, as I mentioned in the invitation letter to this 
hearing, was ``to identify any legislative, regulatory, 
administrative, or funding barrier or issues that prevent or 
impede Alaskan veterans from receiving the best possible care, 
and to finalize work on overcoming these barriers, fixing these 
issues, and ultimately fixing the implementation of the Choice 
Act for Alaskans.''
    With that, I am honored to have our first panel before us. 
We have Mr. Verdie Bowen, who is the director of the Office of 
Veterans Affairs for the State of Alaska; Mr. David Joslin, who 
is an Alaskan veteran; Susan Williams, also an Alaskan veteran; 
and Mr. Walter Watts, commander of the VFW for the entire State 
of Alaska who was good enough to be one of the witnesses in 
Fairbanks yesterday and has come down here again in Eagle River 
to be on an official Veterans' Affairs Committee panel this 
evening.
    With that, I would welcome the opening statements of each 
of our witnesses, and we will then proceed with questions.
    We will start with you, Mr. Bowen.

    STATEMENT OF VERDIE BOWEN, DIRECTOR, OFFICE OF VETERANS 
                    AFFAIRS, STATE OF ALASKA

    Mr. Bowen. First, I would like to thank you for allowing me 
to come speak on behalf of the veterans of the State of Alaska. 
I am truly honored to be invited to this hearing. The issues 
that we have before us, I believe they can be fixed. We are 
Alaskans. We like to fix things, and I think that we can do 
that.
    If you go back through time, I sort of have to take us back 
a little ways, and think about the last 7 years in Alaska, 
where we came from to today. Seven years ago, most veterans had 
to go to Seattle if they wanted anything, just about. If they 
needed any surgeries, if they needed cancer treatment, you name 
it, they went to Seattle. We had very limited community-based 
outpatient clinics for the veterans to go to.
    Virtually, it was nonexistent for the veteran to get health 
care from Ketchikan to Barrow, if you will. In those 
communities, it was going to be a real tough show.
    What happened after that is that we sat down and started 
looking at ways to change the way we deliver care to our 
veterans. It started with Care Closer to Home. The veterans 
were getting their health care in their communities, from 
doctors in their communities, and they did not have to go to 
Seattle for cancer treatments, if they chose.
    Also with that, we also have the joint venture, the DOD-VA 
joint venture facility on Elmendorf, which is another facility 
that was a great plus for our veterans within the State and 
expanded care out even more.
    After that, we expanded the care to the VA Alaska Native 
Healthcare System, which in turn took our five little clinics 
into now 127 clinics across the State that allowed veterans to 
get care anywhere they were at.
    Then after that, we started the Patient-Centered Community 
Care (PC3) contract, which allowed another network of care 
within the system that allowed veterans to get health care 
within the communities.
    The sad part about all of this is that in June, not too 
long ago, that was abruptly halted. Just prior to that, the 
President signed into law the Veterans Choice Act.
    Now, I understand the Choice program for each veteran, and 
that each one of us who lives in the State of Alaska got a card 
and we were exempt from the 40-mile limits. The problem is that 
the program in itself was not ready for prime time. The moment 
we lost all of the funding to cover the care that we had for 
purchased care throughout the State of Alaska, it immediately 
left our veterans in the lurch.
    Most of us who serve our veterans received hundreds of 
phone calls immediately because they had appointments that they 
had made that were canceled instantly. I always like to share 
stories so people sort of get an idea of what this is like. We 
had several veterans who were scheduled for colonoscopies who 
had gone through the prep, went to the hospital only to 
discover that the appointment had been canceled because there 
was no funding for the appointment. They were ready to go 
through the procedure, but there was no funding.
    We have had veterans who had surgeries that at the end of 
the surgery discovered that they were supposed to call the 
Choice program, and there was no funding for that as well. 
Those are some of the things that we have run into.
    The problem that we really run into in this whole thing is 
that if we look at these issues that we have been dealing with 
the Choice program, you can break each one down and each 
veteran has a different issue, whether they called in, or they 
were hung up on, or they were told that they were within 40 
miles of a facility to go to the facility. That is all good, 
but what the issue really comes down to is that most of the 
people they spoke to were out of State. They had no point of 
reference, so these veterans could explain to the individual on 
the other end of the phone what was going on with them, but the 
person on the other end of the phone had no reference point.
    That goes even a little bit further. Prior to June, 98 
percent of all of our veterans were covered by health care 
somewhere. They were covered by the VA, and they were covered 
with quality health care. After June, the backup system, which 
is the Choice program, you really have to call it what it is, 
the Choice program was established. If a veteran could not get 
an appointment within 30 days, he was to call that number and 
establish an appointment at that time.
    Prior to June, the veterans got all their appointments 
prior to 30 days. The VA was doing an outstanding job caring 
for our veterans from one side of the State to the other. What 
happened after June really was--I guess you would want to say 
it is a black eye to the local VA. That is the sad part, 
because the local VA has probably some of the hardest working 
staff that we have. They had to set up special teams. They had 
to set up special programs to help veterans to call in, because 
they could not get their appointments or they spent 3 or 4 
hours on the phone or they spent days on the phone with no 
callback. The only recourse that they had was to either call 
the State of Alaska legislators, the Federal legislators, the 
local VA, or my office. Most of us have files of hundreds of 
people who have called us because they were unable to make 
appointments.
    The problem that we run into at that point in time is that 
there is no place for us to even turn except to call the same 
number to try to get through to get them their appointments and 
get them established into these things.
    Now one might say that the appointments were difficult. But 
they were not difficult. I will give you an example. Down at 
the community-based outpatient clinic in Kenai, we had a 
veteran who needed an x-ray, just a simple x-ray, and that 
person was instructed to call the Choice program in order to 
get the x-ray done. Well, the x-ray took almost 30 days. It 
should have taken only just a few hours. In the past, it would 
have taken just a few hours by the VA.
    The issue now is that the individual had to work through 
the local VA office in order to get this done through the 
Choice program.
    Now, I believe that some of the ideas that might work to 
fix this thing is that, first of all, we need a better 
oversight of the prime contractor. Now we can name a 
contractor. It does not matter who that person is. But there 
has to be a place where that veteran can call when they are not 
getting the appointments. There has to be a place where that 
veteran can call when they are having difficulty with somebody 
hanging up on them or they are being stuck on hold for hours on 
end. There has to be a place outside of that call center that 
they can reach.
    Whether that is set up by the prime contractor or that is 
set up by the VA, there needs to be a different call center 
that they can call once all those failures have happened, 
because the problem is that they call my office and immediately 
we are on the same phone calling the same number that they just 
did. Our legislative staffs are doing the same thing for our 
veterans across the State. We are still not reaching that end 
goal to where they are getting those appointments in a timely 
manner.
    The other thing too is that we had the best VA system in 
the Nation. When Tucson had its problems, when I looked around 
Alaska, our veterans were being treated. The complaints that we 
were receiving at the time was that they were telling us about 
relatives who lived in other States and other issues that were 
happening in other States.
    Well, we did not start having issues in our State until all 
the funding was pulled out of our programs. Once that funding 
was pulled, then our veterans were unable to be seen.
    If it is a model program for the Nation, we need to keep 
that model program in place and then allow the Choice program 
to mature over time like it should, because if you go back in 
time, it took 7 years to develop the programs we have today--7 
whole years. The Choice program cannot be a program of choice 
in 30 days. That is an impossible feat. I could not even do 
that with my staff. The VA has had to shore up this problem 
with internal staff to try to fix this stuff, and it is really 
not fixable.
    The last issue that I really want to talk about that deals 
with the Choice program that really needs to be addressed deals 
with the payer of last resort. If you have a veteran who is 50 
percent or greater disabled treated in a local clinic through 
the Choice program--and that issue is not related to their 
disability--say, for instance, their disability is head and 
back and they go in to get treated for their foot, and their 
spouse has medical coverage. The deductible is several thousand 
dollars, that veteran is going to pay that deductible, because 
under the payer of last resort, your primary insurance, which 
is going to be held in your family, is going to be billed for 
that process and the VA will be paid last. If there are 
deductibles, that is going to fall upon that veteran. That is a 
small gap that we have within this that is going to happen.
    Some of these veterans who are greater than 50 percent, or 
you could even say full and total at 100 percent, cannot afford 
some of those deductibles their spouse might have at their 
small job or whatever they might be doing. That is something 
that we need to look at.
    The last thing, we really should mature the systems that we 
have currently in place in Alaska, fund them at the full amount 
at $127 million, either exempt the State from the Choice 
program or allow the Choice program to mature over time and use 
it like it was intended to be used as veterans' choice, not 
like it is today where it is the primary insurance plan.
    [The prepared statement of Mr. Bowen follows:]
         Prepared Statement of Verdie A. Bowen, Sr., Director, 
              Office of Veterans Affairs, State of Alaska
    I am truly honored and thank you for inviting me to testify at this 
field hearing focused on the Veterans Choice Program and the problems 
surrounding this program delivering care to our veterans in Alaska.
    Before I jump into the Choice Program I need to express the 
different programs used in Alaska and how we use these programs for the 
delivery of health care to our veterans.
    Over the past seven years we have worked to forge partnerships that 
will allow our veterans to receive their care closer to home. We have 
set into place the DOD/VA Joint Venture agreement, the Care Closer to 
Home initiative, and the VA/Alaska Native Healthcare partnership 
agreements with 26 Alaska Native Health Care programs. We have come a 
long way to deliver care to our veterans and build on the trust 
required to provide medical services to those we serve. Without these 
new care programs, veterans are limited to care inside the five VA 
facilities only, which are located in Fairbanks, Wasilla, Anchorage, 
Kenai, and Juneau. Also the VA holds a weekly Monday clinic in Homer 
Alaska.
    We have worked hard to forge agreements between all our partners. 
Alaska needed local solutions to ensure our veterans were offered the 
highest quality of health care and services. Our biggest challenges are 
the location of the communities across the state. We have 348 
communities with 166 located off the road system. No other state 
experiences the cost of health care travel our veterans face and the 
lack of sustained health care in their communities.
    We first started looking at ways to ensure all our veterans 
received quality care regardless of where they live. We collectively 
worked from the understanding that:

     There are disparities and differences in health status 
between rural (off the road system) and urban (on the road system) 
veterans. According to the VA's Health Services Research and 
Development Office, comparisons between rural and urban veterans show 
that rural veterans ``have worse physical and mental health related 
issues due to limited care.''
     More than 44 percent of military recruits, and those 
serving today come from rural areas.
     A large number of activated Alaska National Guard members 
come from our rural communities.
     With the highest number of per capita of veterans in the 
Nation we have a large number without access to emergent/urgent care.

    We started looking at in house ways to bridge gaps with the 
programs we already have in Alaska. The Anchorage DOD/VA Joint Venture 
is located where over 42,000 Alaska veterans live. This program 
provides urgent and emergent care the VA cannot. The VA located a 
Community Based Outpatient Clinic (CBOC) in the Basset Army Medical 
facility in Fairbanks covering care needs for another 12,500 veterans. 
The next move was the ``Care Closer to Home'' program providing local 
purchase care for our veterans where they live.
    Our veterans in the past had to travel to the lower 48 for major/
minor surgeries and all cancer treatments. This was a one size fits all 
mentality and the veteran either paid for the trip out of pocket or the 
VA funded the travel if the illness was related to a disability caused 
through their service. The sad part was in most cases the medical care 
could have been purchased locally. The worst part for our veterans 
being most were either too old or too frail to make the trips and most 
suffered additional issues due to the travel. If the veteran needed 
cancer treatments this meant staying at a local hotel before and after 
the treatment placing the veteran at risk of additional medical issues 
and increasing the cost of their care.
    Past Secretary of the VA Eric Shinseki authorized the Care Closer 
to home program and immediately we saw not only an increase in VA 
utilization we experienced for the first time a reduction in our daily 
health care complaints. It was common to have in my office each Monday 
an average of 60 complaints due to health care related issues. This 
number dropped to just under 20 once this program was in full stride 
and most of these issues were contributed to rural travel.
    In our rural communities, Alaska native veterans and non-native 
veterans had all but given up hope that they could ever use their 
earned benefits. A large number had not enrolled in the VA Health Care 
program because they had to pay for the cost of travel to a VA 
facility. In most cases seeking care locally, even though expensive, 
was cheaper than a flight to a VA clinic. In reality most just gave up 
and only requested care when the medical issue needed emergent/urgent 
care.
    Again, Past Secretary of the VA Eric Shinseki stepped in and 
established the 13 Medical Working Group. Each of us on the board was 
challenged to find a working solution for rural health care. Within 6 
months, the VA/Alaska Native Heath Care Partnership was formed and over 
the next 24 months all 26 Alaska Native Sharing agreements were signed. 
These agreements allowed veterans to be treated in the local native 
clinics across Alaska. This was the first agreement in the Nation of 
this kind. In Alaska it added another 122 facilities that our veterans 
had access to. This was the first time in Alaska that 98% of our 
veterans lived close to or in a community that provided healthcare.
    It is easy to understand the VA would like to have a one size fits 
all program and make Alaska look like the lower 48 but this is not a 
reality and we have to always work together to see what programs work 
best for our veterans. Passing laws and programs without first taking 
into account our unique issues will cause our veterans to lose their 
access to healthcare benefits. It takes time to establish new programs 
and most of all it takes longer to build the trust required to 
establish these programs. The three programs I discussed above took 
years to mature and they still have room for improvement.
    We have come too far in our delivery of services to our veterans to 
turn back now. While the VA facilities in the lower 48 were struggling 
under the burden of old policies and procedures, Alaska has 
successfully entered into new agreements and care models. Due to these 
models we are able to keep our primary care back log down and our 
programs became the model for the rest of the Nation. Even with doctor 
shortages throughout the state our programs continued to provide great 
service to our veterans. When we held listening sessions around the 
state our veterans continually thanked the VA for the healthcare proved 
locally.
    Late June 2015 all funding for the Care Closer to Home, DOD/VA 
Joint Venture, and the VA/Alaska Native program was pulled. Over night 
8,000 veterans were without coverage through these three programs and 
they were instructed to use the Veterans Choice program. Each veteran 
went from outstanding local care to a program that could not provide 
access to local care. I do understand the reason for issuing every 
veteran in Alaska the Veterans Choice Card and its overall concept has 
merit. The issue we have in Alaska is the program did not take the time 
like the others to build trust or ensure a network of care was 
available before it was thrust on the veterans seeking health care.
    Some of funds for our existing programs have been restored after a 
recent visit by Secretary McDonald. This has helped us continue 
treatment for our veterans across the state but it did not fix the 
issues with the Choice Program. In reality we still do not have the 
structure in Alaska to cover the basic needs of our veterans using the 
Choice Program. In order for the program to have any future success, it 
will take time to build a network of care providers. Today this program 
is still in the first stages of infancy. Most nonnative and native 
medical facilities will not participate in the Choice Program due to 
issue with appointments, the slow payment process, and even with an 
increase in payments they still do not cover the cost of care. On top 
of these three concerns shared by the medical community the veteran now 
has another level of bureaucracy between them and their care. .
    Today only a few of our veterans are using this card by choice. 
Most are forced into the program due to the lack of care at the VA 
facility. For example, if a veteran being treated at the Kenai VA 
Community Based Outpatient Clinic (CBOC) is requested to receive an x-
ray. The doctor will place the order in the system and the veteran has 
to call the Choice call center and request the x ray. Doctor's notes 
sometimes don't make it through the system and the veteran must spend 
hours on the phone to work through this in order to receive the 
required test. To help this process along the Alaska VA Medical system 
has created a new team of nurses but it still takes hours if not days 
to ensure the veteran receives the care requested by the doctor. If the 
facility, that is required to assist the veteran, is not enrolled into 
the Choice program this takes even longer.
    In the past, when the veteran was treated at the same CBOC, the 
doctor placed the request in the system and the appointment was set up 
by the local VA staff. The veteran was called with a time and place for 
the test/procedure. The veteran did not have to worry about the bill or 
placing the proper paperwork into the hands of the care provider. This 
was taken care of by VA staff and if questions were asked they were 
taken care of on the spot. Under Choice this becomes a never ending 
loop.
    The Veterans Choice and Accountability Act of 2014 has merit on 
paper and could develop into a quality program over time. The issue 
experienced by Alaskan veterans was caused by the rapid defunding of 
our existing stellar programs and thrusting their care into an untested 
program. It would help our veterans even more if the prime contractor 
for the Choice program would establish an office in Alaska to help 
mature this program. We do have areas that need to be improved upon 
before the choice program can reach its full potential.
    First we need to ensure our existing programs will never befall 
another mid fiscal year loss of funds. No matter the reason or the 
cause of the funds being pulled the best way to ensure this rapid 
deceleration of funds will not occur again is to create a single line 
item in the VA budget that covers the $127M needed to fund all three 
programs that serve our veterans through the following: local purchased 
care, Alaska Native Health Care program, and the DOD/VA Joint Venture. 
This will provide trust to those providing the care and those receiving 
the care.
    Next, allow the Choice program to mature. If the program is 
extended it needs to have some critical changes to survive in the 
Alaskan environment. The payments for care should match what the VA 
currently pays under its existing programs. Next, if a veteran is 50% 
or greater disabled or seen for a service-connected condition than the 
veteran should not pay any copayments and be treated the same as if he/
she is treated at a VA medical facility. Change the Choice program from 
payer of last resort and make it match the current purchased care 
program provided by the VA. This way when a third party insurance 
collection is collected it goes back to the VA. Not like today when the 
veteran is covered by insurance the Choice pays last and the veteran is 
stuck will all deductibles regardless of disability rating. My office 
as of today has received over 500 calls by veterans who have discussed 
dropping their insurance coverage due to high deductibles. In the end 
this does help the veteran and the local VA will lose over $20M from 
insurance collections.
    The Choice program needs to return to its original concept of a 
program that provides a choice to veterans. This should not be the 
program forced upon the veteran because of budget shortfalls. It was 
not developed for this type of service to our veterans nor was it 
intended for this type of coverage. Because of the forced utilization 
of this program it has caused broken trust and has severely discredited 
the VA system the Alaska veteran has utilized in the past. In Alaska we 
understand this new program was a knee jerk reaction to the issues 
experienced by our fellow veterans in the lower 48. Alaska should have 
been exempt from this program because we did not experience the issues 
faced in other states.
    The primary contractor needs to be held to a higher level of 
accountability. The VA and the State of Alaska has been briefed several 
times that a local call center will be developed and that more doctors 
and medical facilities will be enrolled into the Choice program. We 
have passed the three week promised time for the call center and we 
still have few medical facilities and doctors enrolled in this program. 
What we have seen is the local VA Medical Center Staff, the 
Congressional Delegation, and the State of Alaska filling this role to 
facilitate calls for our veterans and find medical facilities and staff 
that will take the Choice program.
    In summary, over the past seven years all Alaskans who provided 
services to our veterans have worked hard and created strong 
partnerships with the VA to ensure Alaska's veterans are well cared 
for. We have come a long way in our ability to provide equal care to 
veterans on and off the road system. I know the VA has funding 
challenges and so does Alaska. However, when the time comes to 
prioritize spending, we cannot do so at the risk of failing to keep our 
promises to our veterans. As a Nation, we wrote the check when we sent 
them to war, and now it is incumbent on all of us to honor that 
agreement and their service. I urge the U.S. Senate to continue funding 
the programs greatly needed by the Alaska Veterans and to make critical 
changes to the Choice program that will allow veterans to never go 
without the healthcare they have earned.

    Thank you for the privilege and honor of addressing this hearing on 
behalf of the Alaskan Veterans.
                                 ______
                                 
                                Addendum
    I am truly honored and thank you for inviting me to testify at this 
field hearing focused on the Veterans Choice Program and the problems 
surrounding this program delivering care to our veterans in Alaska.
    Before I step into my testimony about the care and our veterans in 
Alaska, I must discuss the vastness of Alaska and the complications/
challenges they face.
                              background:
    According to the U.S. Census 2012 Alaska's total population was 
731,449 compared to the total U.S. population estimated at 313,914,040. 
Alaska in land mass is almost 1/3 that of the continental U.S. 
accounting for approximately 663,268 square miles, compared to the U.S. 
land area in square miles which equals approximately 2,531,905 square 
miles. That equates to 1.2 people per square mile in Alaska compared to 
87.4 people per square mile in the mainland U.S. The map below 
illustrates the size comparison of Alaska compared to the lower 48 
states and the lines represent the travel requirements of Alaska's 
Veteran Service Organizations utilizing train, plane, boat, snowmobile, 
and ATV.




    Aside from its large size, most of Alaska is considered rural, 
remote, or frontier. Unlike the lower 48 states, Alaska's road system 
is almost non-existent. Technically, there is only one paved highway in 
the entire state. This mostly two-lane highway provides connectivity 
between the state's largest urban community, Anchorage and several 
rural communities located in the Gulf Coast Region (Mat-Su valley, 
which is a suburb 45 miles to the North of Anchorage, the Kenai 
Peninsula which extends 200 miles south of Anchorage and includes the 
communities of Kenai, Soldotna, and Homer; Seward, which is 150 miles 
south from Anchorage, Valdez, located 300 miles southeast from 
Anchorage and Fairbanks, which is located, 359 miles north from 
Anchorage and is part of interior Alaska).
    Everywhere else in the state the primary means of travel is either 
by Jet (to larger hub communities), small aircrafts and/or boats to 
rural and remote communities, or by the Alaska Ferry Highway System in 
SE Alaska. There are some paved or gravel logging roads on larger 
Islands like Kodiak and Prince of Wales Island, but these roads are 
limited between select communities and/or logging camps.
    Travel in Alaska can be expensive. A plane from Juneau to Barrow is 
comparable to the travel costs from Orlando to New York with a round 
trip ticket costing anywhere from $850 to $1,500. However, due to the 
extreme geography and weather conditions, costs associated with 
medevac's in Alaska can be much higher than in the lower 48 states and 
range from $20,000 to over $150,000 depending on a variety of factors 
including: pickup location, miles traveled, size of aircraft, and any 
necessary emergency medical attention needed on the aircraft.
    A veteran living in Sitka Alaska has two choices getting to the 
Alaska VA Healthcare System (AVAHS) located in Anchorage. First, by 
boat connecting to the road system which is 992 miles one way or second 
the more direct path is by air travel at 580 miles. Most veterans 
traveling this great distance may have extreme physical disabilities or 
medication that must be monitored periodically. The veteran is required 
to be in the local area the day before their appointment and sometimes 
due to extreme weather will be brought into the area several days in 
advance, or worst case, miss the appointment due to canceled aircraft 
or watercraft.
    On an average the veteran and the travel office expends an 
additional 42 man-hours monthly to ensure the veteran is provided 
medical services. AVAHS travel desk expends $3,500,000.00 on average to 
travel veterans from highly rural areas in Alaska. This model was the 
one we used to look for ways to change the delivery of healthcare for 
our veterans in Alaska. After a visit by Secretary Shinseki in 2011 we 
started to explore alternatives to this costly venture and tried to 
establish a plan that allowed veterans to have care closer to home. We 
do have commutes much further away than Sitka and that take much longer 
to arrive at the AVAHS facility in Anchorage. This location just helped 
us to establish a baseline to work on plans for alternative care.
    The Alaska Department of Veteran Affairs outpatient medical 
facility is located next to the Department of Defense's Joint Bases 
Elmendorf/Richardson (JBER) in Anchorage. The facilities are connected 
by a tunnel and the DOD facility provides the inpatient care for the 
veterans of Alaska. This is one of two joint use facilities in Alaska. 
The other facility is at Ft. Wainwright located by Fairbanks. We have 
three other Community Outpatient Clinics (CBOCs) and they are located 
in Kenai, Wasilla, and Juneau. Juneau, the capital of Alaska, is not 
connected to the road system and only has access by boat or plane. This 
CBOC serves all veterans located on the Alaskan panhandle totaling 
hundreds of islands and 135 communities. The Kenai CBOC which serves 
veterans who reside within the 16,000 square miles on the Kenai 
Peninsula also has an outreach clinic once a week at the South 
Peninsula Hospital to serve Homer and the smaller satellite communities 
located on the islands off the coast. The need for a new way to deliver 
healthcare was needed. Serving all Alaska by five clinics is nearly 
impossible and equality for our veterans living off the road system was 
in disarray.
                           developing a plan:
    Over the past seven years we have worked to forge partnerships that 
will allow our veterans to receive their care closer to home. We have 
set into place the DOD/VA Joint Venture agreement, the Care Closer to 
Home initiative, and the VA/Alaska Native Healthcare partnership 
agreements with 26 Alaska Native Health Care programs. We have come a 
long way to deliver care to our veterans and build on the trust 
required to provide medical services to those we serve. Without these 
new care programs, veterans are limited to care inside the five VA 
facilities only, which are located in Fairbanks, Wasilla, Anchorage, 
Kenai, and Juneau. Also the VA holds a weekly Monday clinic in Homer 
Alaska.
    We have worked hard to forge agreements between all our partners. 
Alaska needed local solutions to ensure our veterans were offered the 
highest quality of health care and services. Our biggest challenges are 
the location of the communities across the state. We have 348 
communities with 166 located off the road system. No other state 
experiences the cost of health care travel our veterans face and the 
lack of sustained health care in their communities.
    We first started looking at ways to ensure all our veterans 
received quality care regardless of where they live. We collectively 
worked from the understanding that:

     There are disparities and differences in health status 
between urban, rural, and frontier veterans. According to the VA's 
Health Services Research and Development Office, comparisons between 
rural and urban veterans show that rural veterans ``have worse physical 
and mental health related issues due to limited care.''
     More than 44 percent of military recruits, and those 
serving today come from rural areas.
     A large number of activated Alaska National Guard members 
come from our rural communities.
     With the highest number of per capita of veterans in the 
Nation we have a large number without access to emergent/urgent care.

    We started looking at in house ways to bridge gaps with the 
programs we already have in Alaska. The Anchorage DOD/VA Joint Venture 
is located where over 42,000 Alaska veterans live. This program 
provides urgent and emergent care the VA cannot. The VA located a 
Community Based Outpatient Clinic (CBOC) in the Basset Army Medical 
facility in Fairbanks covering care needs for another 12,500 veterans. 
The next move was the ``Care Closer to Home'' program providing local 
purchase care for our veterans where they live.
    Our veterans in the past had to travel to the lower 48 for major/
minor surgeries and all cancer treatments. This was a one size fits all 
mentality and the veteran either paid for the trip out of pocket or the 
VA funded the travel if the illness was related to a disability caused 
through their service. The sad part was in most cases the medical care 
could have been purchased locally. The worst part for some of our 
veterans is they are either too old or too frail to make the trips and 
most suffered additional issues due to the travel. If the veteran 
needed cancer treatments this meant staying at a local hotel before and 
after the treatment placing the veteran at risk of additional medical 
issues and increasing the cost of their care.
    Past Secretary of the VA Eric Shinseki authorized the Care Closer 
to home program and immediately we saw not only an increase in VA 
utilization we experienced for the first time a reduction in our daily 
health care complaints. It was common to have in my office each Monday 
an average of 60 complaints due to health care related issues. This 
number dropped to just under 20 once this program was in full stride 
and most of these issues were contributed to rural travel.
    In our rural communities, Alaska native veterans and non-native 
veterans had all but given up hope that they could ever use their 
earned benefits. A large number had not enrolled in the VA Health Care 
program because they had to pay for the cost of travel to a VA 
facility. In most cases seeking care locally, even though expensive, 
was cheaper than a flight to a VA clinic. In reality most just gave up 
and only requested care when the medical issue needed emergent/urgent 
care.
    Again, Past Secretary of the VA Eric Shinseki stepped in and 
established the 13 Medical Working Group. Each of us on the board was 
challenged to find a working solution for rural health care. Within 6 
months, the VA/Alaska Native Heath Care Partnership was formed and over 
the next 24 months all 26 Alaska Native Sharing agreements were signed. 
These agreements allowed veterans to be treated in the local native 
clinics across Alaska. This was the first agreement in the Nation of 
this kind. In Alaska it added another 122 facilities that our veterans 
had access to. This was the first time in Alaska that 98% of our 
veterans lived close to or in a community that provided healthcare.
    It is easy to understand the VA would like to have a one size fits 
all program and make Alaska look like the lower 48 but this is not a 
reality and we have to always work together to see what programs work 
best for our veterans. Passing laws and programs without first taking 
into account our unique issues will cause our veterans to lose their 
access to healthcare benefits. It takes time to establish new programs 
and most of all it takes longer to build the trust required to 
establish these programs. The three programs I discussed above took 
years to mature and they still have room for improvement.
    We have come too far in our delivery of services to our veterans to 
turn back now. While the VA facilities in the lower 48 were struggling 
under the burden of old policies and procedures, Alaska has 
successfully entered into new agreements and care models. Due to these 
models we are able to keep our primary care back log down and our 
programs became the model for the rest of the Nation. Even with doctor 
shortages throughout the state our programs continued to provide great 
service to our veterans. When we held listening sessions around the 
state our veterans continually thanked the VA for the healthcare proved 
locally.
                   current issues our veterans face:
    Late June 2015 all funding for the Care Closer to Home, DOD/VA 
Joint Venture, and the VA/Alaska Native program was pulled. Over night 
8,000 veterans were without coverage through these three programs and 
they were instructed to use the Veterans Choice program. Each veteran 
went from outstanding local care to a program that could not provide 
access to local care. I do understand the reason for issuing every 
veteran in Alaska the Veterans Choice Card and its overall concept has 
merit. The issue we have in Alaska is the program did not take the time 
like the others to build trust or ensure a network of care was 
available before it was thrust on the veterans seeking health care.
    Some of funds for our existing programs have been restored after a 
recent visit by Secretary McDonald. This has helped us continue 
treatment for our veterans across the state but it did not fix the 
issues with the Choice Program. In reality we still do not have the 
structure in Alaska to cover the basic needs of our veterans using the 
Choice Program. In order for the program to have any future success, it 
will take time to build a network of care providers. Today this program 
is still in the first stages of infancy. Most nonnative and native 
medical facilities will not participate in the Choice Program due to 
issue with appointments, the slow payment process, and even with an 
increase in payments they still do not cover the cost of care. On top 
of these three concerns shared by the medical community the veteran now 
has another level of bureaucracy between them and their care.
    Today only a few of our veterans are using this card by choice. 
Most are forced into the program due to the lack of care at the VA 
facility. For example, if a veteran being treated at the Kenai VA 
Community Based Outpatient Clinic (CBOC) is requested to receive an x-
ray. The doctor will place the order in the system and the veteran has 
to call the Choice call center and request the x-ray. Doctor's notes 
sometimes don't make it through the system and the veteran must spend 
hours on the phone to work through this in order to receive the 
required test. To help this process along the Alaska VA Medical system 
has created a new team of nurses but it still takes hours if not days 
to ensure the veteran receives the care requested by the doctor. If the 
facility, that is required to assist the veteran, is not enrolled into 
the Choice program this takes even longer.
    In the past, when the veteran was treated at the same CBOC, the 
doctor placed the request in the system and the appointment was set up 
by the local VA staff. The veteran was called with a time and place for 
the test/procedure. The veteran did not have to worry about the bill or 
placing the proper paperwork into the hands of the care provider. This 
was taken care of by VA staff and if questions were asked they were 
taken care of on the spot. Under Choice this becomes a never ending 
loop.
    The Veterans Choice and Accountability Act of 2014 has merit on 
paper and could develop into a quality program over time. The issue 
experienced by Alaskan veterans was caused by the rapid defunding of 
our existing stellar programs and thrusting their care into an untested 
program. It would help our veterans even more if the prime contractor 
for the Choice program would establish an office in Alaska to help 
mature this program. We do have areas that need to be improved upon 
before the choice program can reach its full potential.
                          needed improvements:
    First we need to ensure our existing programs will never befall 
another mid fiscal year loss of funds. No matter the reason or the 
cause of the funds being pulled the best way to ensure this rapid 
deceleration of funds will not occur again is to create a single line 
item in the VA budget that covers the $127M needed to fund all three 
programs that serve our veterans through the following: local purchased 
care, Alaska Native Health Care program, and the DOD/VA Joint Venture. 
This will provide trust to those providing the care and those receiving 
the care.
    Next, allow the Choice program to mature. If the program is 
extended it needs to have some critical changes to survive in the 
Alaskan environment. The payments for care should match what the VA 
currently pays under its existing programs. Next, if a veteran is 50% 
or greater disabled or seen for a service-connected condition than the 
veteran should not pay any copayments and be treated the same as if he/
she is treated at a VA medical facility. Change the Choice program from 
payer of last resort and make it match the current purchased care 
program provided by the VA. This way when a third party insurance 
collection is collected it goes back to the VA. Not like today when the 
veteran is covered by insurance the Choice pays last and the veteran is 
stuck will all deductibles regardless of disability rating. My office 
as of today has received over 500 calls by veterans who have discussed 
dropping their insurance coverage due to high deductibles. In the end 
this does help the veteran and the local VA will lose over $20M from 
insurance collections.
    The Choice program needs to return to its original concept of a 
program that provides a choice to veterans. This should not be the 
program forced upon the veteran because of budget shortfalls. It was 
not developed for this type of service to our veterans nor was it 
intended for this type of coverage. Because of the forced utilization 
of this program it has caused broken trust and has severely discredited 
the VA system the Alaska veteran has utilized in the past. In Alaska we 
understand this new program was a knee jerk reaction to the issues 
experienced by our fellow veterans in the lower 48. Alaska should have 
been exempt from this program because we did not experience the issues 
faced in other states.
    The primary contractor needs to be held to a higher level of 
accountability. The VA and the State of Alaska has been briefed several 
times that a local call center will be developed and that more doctors 
and medical facilities will be enrolled into the Choice program. We 
have passed the three week promised time for the call center and we 
still have few medical facilities and doctors enrolled in this program. 
What we have seen is the local VA Medical Center Staff, the 
Congressional Delegation, and the State of Alaska filling this role to 
facilitate calls for our veterans and find medical facilities and staff 
that will take the Choice program.
    In summary, over the past seven years all Alaskans who provided 
services to our veterans have worked hard and created strong 
partnerships with the VA to ensure Alaska's veterans are well cared 
for. We have come a long way in our ability to provide equal care to 
veterans on and off the road system. I know the VA has funding 
challenges and so does Alaska. However, when the time comes to 
prioritize spending, we cannot do so at the risk of failing to keep our 
promises to our veterans. As a Nation, we wrote the check when we sent 
them to war, and now it is incumbent on all of us to honor that 
agreement and their service. I urge the U.S. Senate to continue funding 
the programs greatly needed by the Alaska Veterans and to make critical 
changes to the Choice program that will allow veterans to never go 
without the healthcare they have earned.

    Thank you for the privilege and honor of addressing this hearing on 
behalf of the Alaskan Veterans.

    The Chairman. Thank you. Thank you very much, Mr. Bowen.
    Dr. Joslin.

               STATEMENT OF DAVID JOSLIN, VETERAN

    Mr. Joslin. Thank you, Senator. It is actually Mr. Joslin. 
I do not want to take away from any physician.
    The Chairman. I always like promoting people.
    Mr. Joslin. My name is David Joslin. Thank you for asking 
me to be here. I am the administrator of Diagnostic Health 
Anchorage, and I am also the manager of operations for the 
State of Alaska for Alliance Health Care Services. On top of 
that, I am also a retired sergeant first class in the U.S. 
Army. I am also a service-connected disabled veteran and a 
beneficiary of the Alaska VA Health System.
    I have the unique perspective of witnessing the compounding 
issues with regard to the Choice program from both a 
beneficiary's perspective and a private-sector business 
partner's perspective. I am sure you have heard countless 
examples of how the program's implementation has affected 
veterans and their health care. Today I want to talk to you 
more specifically about the impact it has had on the private-
sector business partners.
    Once word of my participation on this panel became public 
within the Anchorage medical community, I received an 
outpouring of requests from other medical offices to speak with 
me before I got here today so that I could potentially be a 
collective voice for the medical community in Anchorage and 
relay some of the things that not just my practice has seen but 
other practices throughout the community.
    Across the board in Anchorage, the medical community has 
experienced some of these common problems: patients being 
scheduled prior to authorizations being completed, which for us 
results in nonpayment for services that are already rendered; 
overall, 1-to-2-month delays in referral processing; delays in 
payment processing; major losses of work productivity in our 
medical offices as our nurse assistants, medical assistants, 
and nursing staff are on hold for 30 to 45 minutes at a time, 
waiting for Choice to pick up so we can begin to coordinate 
care; an apparent lapse of access to care standards; and an 
overall disregard for continuity of care.
    More specifically for medical providers that had--and I say 
``had''--a contract with the VA prior to this, such as myself, 
I present the following, specifically my case with my contract 
with the VA. In February 2013, my company was awarded the 
Alaska VA Healthcare System exclusive private-sector contract 
for diagnostic imaging services. These were for referrals 
generated out of the Integrated Care services department off of 
Muldoon. It is a 1-year contract with four optional years built 
into the contract that runs from 1 February to 31 January. We 
are currently in the third year of that contract in the second 
option year.
    Due to the implementation of the Veterans Choice Program 
and a complete change to the referral management system, as of 
May of this year, my contract has essentially been nullified, 
even though the Department of Veterans Affairs has entered into 
a binding agreement for service with my organization and that 
term has not expired yet.
    When I questioned the local program managers at the local 
VA who, to the gentleman's comment to my right, are outstanding 
people to work with and are very easy to work with generally, 
the only answer I got is that they no longer have control over 
the referral of care for veterans.
    When I called provider relations at TriWest, I was very 
abruptly told that their contract was separate and different 
from mine, and that they were under no obligation whatsoever to 
refer any diagnostic imaging business to my practice, 
regardless of my contract with the VA.
    Could somebody tell me how, if I have a binding contractual 
agreement with the VA, how your failed implementation plan no 
longer guarantees my business? Not your implementation plan, 
obviously, but TriWest's and the VA's implementation plan.
    My contract, as I am sure many other contracts state in the 
contract language, states that, ``Only the contracting officer 
is authorized to make commitments or issue changes that will 
affect price, quantity, or quality of performance of this 
contract.'' Yet, when I attempted to work with my assigned 
contracting officers from the VISN 20 office, I was informed 
that she was just as in the dark on the changes as I was.
    Given this, the VA as a whole, in my opinion, knowingly 
ignored and disregarded their own contracting processes and 
obligations.
    Where do we go from here?
    The first question from the medical community at large is, 
is the Veterans Choice Program, repealable? Can this be undone? 
If it is not able to be repealed as a whole, can Alaska, since 
we were doing fine before it, can we be exempt from the program 
and go back to doing business the way that we did before 
Veterans Choice?
    As far as the VA's obligations to contractors such as me, 
in my opinion, the VA has opportunity to make this right. They 
have the opportunity to make good on their commitments.
    First, I am asking that the VA conduct a contractual review 
to identify just how many private-sector contracted business 
partners were negatively impacted by this failed 
implementation. They need to identify just how many contracts 
they negated such as mine in a very poorly planned and rushed 
to market program.
    Second, I am asking that they modify their contract with 
TriWest mandating that they honor the current standing 
contracts such as mine. Fewer and fewer medical providers are 
wanting to do business with the VA because of this program, and 
I think that they should make good use of the ones that still 
value that relationship.
    Pending your questions, Senator, that is all I have today.
    [The prepared statement of Mr. Joslin follows:]
 Prepared Statement of David Joslin, Administrator, Diagnostic Health 
Anchorage; Manager of Operations, State of Alaska, Alliance Healthcare 
             Services; and Sergeant First Class USA (Ret.)
    Good afternoon, my name is David Joslin. I am the Administrator of 
Diagnostic Health Anchorage and the Manager of Operations for the State 
of Alaska for Alliance Healthcare Services. I am also a retired 
Sergeant First Class of our beloved Army, and a 70% service-connected 
disabled veteran and beneficiary of the Alaska VA Health System. 
Additionally, I hold the position of Post Service Officer for the 
Veterans of Foreign Wars, Post-9785 here in Eagle River, Alaska. I have 
the unique perspective of witnessing the compounding issues with regard 
to the failed implementation strategy of the Veteran's Choice program 
from both the VA private sector business partner's vantage point, and 
the personal view of a beneficiary. I am sure you have or will hear 
countless examples of how this program's implementation has had 
negative impacts on the Veteran community in Alaska in today's hearing. 
I too, could provide multiple stories and examples of circumstances and 
situations reported to me from my members at the VFW, from VA patients 
that receive healthcare services at my practice locally or even me 
personally; but I would rather talk to you about another negative 
impact that this program has had as it relates to me as a contracted 
business partner of the Alaska VA Health System.
    In February 2013, my company was awarded the Alaska VA Health 
Systems exclusive private sector contract for diagnostic imaging 
services for VA Beneficiaries referred through the Integrated Care 
Services department. This is a one year contract with 4 optional 
renewal years built into the contract that run from 1 February thru 
31 January for each contract term. We are currently operating in year 3 
of this contract (option #2), which the current period runs from 
February 1st of this year to January 31st of 2016. Due to the 
implementation of the Veterans Choice program and the complete change 
to the referral management system, as of May of this year, my contract 
has essentially been nullified even though the Department of Veterans 
Affairs entered into a binding agreement for service with my 
organization that has not expired. When I questioned the local program 
managers at the Alaska VA Integrated Care office, I was told that they 
no longer have control over the referral of care for Veterans. When I 
called the Provider Relations line at Tri West, I was very abruptly 
told that their contract was separate and indifferent from mine, and 
that they are under no obligation whatsoever to refer any diagnostic 
imaging business to my practice, regardless of my contract with the VA.
    As a publicly traded organization, we pride ourselves on integrity 
and accountability; they are two of our core corporate values. As such, 
we prepared our organization for this fiscal year based upon the 
binding agreement between our organizations and reported these 
strategies and accountable targets to our Executive Team, our Board of 
Directors and our Shareholders. As I am sure you would imagine, the 
change in business volume has gotten the attention of many in my 
organization, and they want answers. So, could somebody please tell me, 
how if I have a binding contractual agreement between my organization 
and the Alaska Veterans Health System, and now, due to your failed 
implementation plan, that I am no longer guaranteed any business from 
you? As a Platoon Sergeant in the Army, none of my various Commanders 
would have ever allowed a failure on my part to affect or permanently 
impact my Platoon and subordinate Soldiers, so why now has this become 
acceptable for an organization whose very foundation is built upon 
Veterans and Veteran Leaders, to conduct business in this manner? If 
your positions were MTOE or TDA assigned military positions in any 
branch of service, you would have been relieved for cause!
    As per section 9, on page 60 of my contract it states specifically 
``Only the Contracting Officer is authorized to make commitments or 
issue changes that will affect price, quantity, or quality of 
performance of this contract.'' Yet, when I attempted to work with my 
assigned Contracting Officer, I was informed that she was just as in 
the dark on the changes as I was, and as such, the VA as a whole, in my 
opinion, knowingly ignored and disregarded their own contractual 
obligations and processes.
    So, where do we go from here? In my opinion, the VA has the 
opportunity to make this right. They have the opportunity to make good 
on their commitments. First, I am requesting that the VA conduct a 
contractual review to identify just how many private sector business 
partners were negatively impacted by this failed implementation. The 
integrity of our entire nation is at stake when you willfully throw 
your obligations aside with no regard. Second, I am asking that you 
modify your contract with Triwest mandating that they honor current 
standing contracts such as mine. Standing behind your commitments and 
holding yourselves accountable is the first step to regaining the 
confidence of the American people and our Veterans. Finally, I am 
asking that to make this right, you automatically honor the final 
optional years in these contracts. The bottom line is that because of 
this debacle, fewer and fewer medical provider wish to do business with 
the VA, so you had better make good use of the ones that still value 
your relationship!
    I would like to thank you all for your time today for this 
important matter and in closing I would remind you that when dealing 
with the Veteran population, we will only respect you when you lead 
from the front.

    Thank you!

    The Chairman. Thank you very much for that testimony.
    Ms. Williams?

              STATEMENT OF SUSAN WILLIAMS, VETERAN

    Ms. Williams. Good evening, Senator. Thank you for letting 
me talk tonight.
    I am a 100 percent disabled veteran. I have been in the VA 
system for 20 years. I am also a registered nurse for over 30 
years, and I have visited in my travels probably about 20 
different VAs. I must say that Anchorage is one of the better 
VAs that I have ever been to. I have never had to wait for 
care. I have always gotten referrals and everything as I needed 
them.
    I am extremely upset and disappointed about the service 
that I have been getting ever since this new Choice system came 
into being. I liked the idea of being able to choose the doctor 
or the place, but I do not think I have even been able to do 
that.
    I am mostly going to give you some examples of what I have 
run into and issues I have had.
    There was a radiology appointment made for me. One of my 
biggest issues with TriWest is that they will not let you make 
your own appointment. They have to make it for you. They do not 
know our schedules, so how can they even do that? They made me 
an appointment with radiology, and I told them that I could not 
go to that appointment. I was having a lot of problems walking. 
As soon as I was better, I would call and tell them to schedule 
the appointment. The lady I talked to said fine, no problems.
    The next day, a lady called me from TriWest, very rude, and 
said that was not acceptable. She would make me the appointment 
and this was my last chance to go if I wanted the appointment.
    I had bilateral knee replacements on May 27. The doctor 
sent all the paperwork they needed to the VA. While I was in 
the hospital 2 days after surgery, and also very high on 
dilaudid, the nurse manager came in and was unable to get me 
home care for the first 2 weeks before the physical therapy 
(PT).
    I had to call the Choice program, tell them what I wanted, 
and then gave her the phone and said, look, I cannot talk to 
you. I am not in a talking condition, so you need to work with 
this lady to get me my home care. I did finally receive my home 
care.
    At the same time, we set up an appointment for physical 
therapy, which I should have started on June 15. When June 15 
rolled around, there was no authorization for physical therapy. 
I called numerous places. I called the VA. I called Choice 
numerous times. It actually took them 6 weeks to get my 
physical therapy approved.
    As a medical professional, I cannot overstate the 
importance of physical therapy. With physical therapy, it is 
critical that you start physical therapy immediately. You can 
have need for additional surgery, you can get muscle 
contractures. You could have to be put back under sedation and 
have those contractures straightened out. You can have loss of 
joint functions. You can have an increased recovery time, which 
is my problem now. There are numerous things that happen when 
you do not get it. You can end up in a wheelchair.
    I finally went to PT. One of the therapists I had known as 
a medical professional said to come in and let me work with you 
and we will ask the VA to authorize it back to the State. I 
went in and went to a few appointments with him. They contacted 
the VA and got it approved--an authorization for me to go to 
physical therapy--and they would pay back to June 15. However, 
I just got a letter in the mail saying that they are not going 
to pay back to June 15.
    I have a letter that says they are and a letter that says 
they are not. To me, the right hand does not know what the left 
hand is even doing.
    I kept calling Choice throughout this 6 weeks and trying to 
explain how important it was. They tried to blame it on the VA 
and said, ``Well, they take a long time to go through 
Integrated Care.'' I told them, no, I have never waited more 
than a week before. Then they said it is in our contract. We 
have to wait 7 to 10 days before we can contact you about an 
appointment.
    If you have a heart attack or if you have heart problems, 
diabetic problems, if you have ulcers or anything, those 30 
days can cost you your life. If a diabetic has a toe ulcer, if 
it turns into gangrene, and that gangrene turns into sepsis, 
you are gone. There is no reason why people should have to 
wait.
    While I was trying to get my physical therapy approved, I 
did get one call from TriWest, stating that I was now 
authorized to go in and see a doctor to have my surgery. That 
was a little late.
    I tried to change the place I went to physical therapy from 
Anchorage over to Eagle River, because I live here, and I had a 
lot of issues with that. First, they did not want to change me. 
Then I had appointments at two places. Then I get a call from 
one company saying, ``Where were you? You had an appointment 
here today.''
    TriWest has done this to me numerous times, never let me 
know I had an appointment, never let me know they scheduled me 
for an appointment. I get calls from these offices saying, 
``Where are you? Why aren't you here?''
    Now I am authorized for two different physical therapists 
in Eagle River.
    Being a medical professional, I knew what would happen if I 
did not get the physical therapy. I want to speak for the 
layperson who has no knowledge of this. They are being pushed 
off from physical therapy. It is dangerous to their life and to 
the way they live. There are all kinds of complications that 
can come from not doing this.
    Another example, I have been seeing a chiropractor for 2 
years. I asked for an extension on that, which was approved. I 
received a call from another chiropractor I have never heard of 
saying, ``Where were you? You had an appointment here.''
    There is no continuum of care. They want you going to this 
place, then this place, then this place. The continuum is gone.
    Like I said before, heart patients, if they need a stress 
test, that could mean their death. Diabetic patients, neuro 
patients, if they have a small image in an x-ray and need an 
MRI, 30 days, that could be very large and inoperable by then.
    They insist that you have to wait 7 to 10 days, just until 
they get the paperwork. It ends up being about 6 weeks.
    In the VA, I deal with a small number of people and those 
people are very caring. This is, like I said, one of the best 
VAs I have been to. Integrated Care, which I use frequently, 
has always gotten me an appointment within a week. When I have 
an out-of-state appointment, they are right there taking care 
of everything for me.
    I had an appointment with my urologist in the middle of the 
month. I called Choice in the middle of July and told them the 
time of the appointment. I still have not heard anything from 
them, so I missed the appointment.
    TriWest has already showed me that they can lead you in the 
wrong direction. They tell you mistruths. A lot of the people I 
have talked to are rude and just hang up on you.
    In conclusion, of all the doctor offices and stuff I have 
talked to here, no one has had anything good to say about 
Choice. I would love to be exempt from this and go back to the 
way we were, because it was a good system. We got the care that 
we needed. That is all I have to say.
    [The prepared statement of Ms. Williams follows:]
          Prepared Statement of Susan Williams, Alaska Veteran
    Good evening, Vet professional VA system for 20 years. Nurse for 30 
years.

     Visited probably 20 different VA's in my travels
     Extremely upset and disappointed at the new Choice system
     Being able to choose Dr./place to go is nice but * * *
         - Made me a radiology appointment and I canceled it. They 
        called and I told them unable to walk, and I would call them 
        about the apt when was able. The lady said no problem. Next 
        day--lady called--not acceptable. She would make appointment. I 
        would go.
         - Had bad knees, May 27, Dr. sent paperwork to VA. While in 
        hospital, nurse manager had to fight to get me home PT x2 
        weeks. Said I had to call Choice and ask for it. Set up an 
        appointment for PT, 15 June--notified Choice.
     Importance of PT
     Additional surgery
     Contractures
     Loss of joint function
     Lengthened recovery time
         - Went to PT--without authorization, Dr. knew me well from 
        previous arthroscopies. Allowed me appointment anyways, went a 
        couple times a week. Continued to contact VA and Choice for 
        authorization, called director's office put in an urgent 
        emergent. Kept calling choice--told me they saw request in 
        computer. Said U/E request sent upstairs but would contact me 
        in 7-10 business days. Claimed it was in contract with VA to 
        wait that amount of time. Asked for a closer PT and had 
        approved Select, so told, no didn't want closer (``rock the 
        boat'')--received phone call, why didn't I make appointment for 
        the closer PT. Told Select that they would authorize back to 6/
        15. Sent me a letter saying no authorization. Waited 4 weeks 
        after I should have started PT, set me way back with (?) nurse. 
        Average lay person?
         - Heart pts:

         - Diabetic pts: ulcer to gangrene
     Loss of limb/life
     Septic
         - Nerve pt: Wait 7-10 days plus
     Seeing same Chiro x2 years, Asked for extension and was 
approved. Received call from another Chiro asking why I didn't show up 
for appointment. NO CONTINUUM of care.
     Won't let make own appointments.
     Deal with same amount of people, very personal and caring
     Tri-West, already showed will lie, and not caring.
     Dr. Nelson--urologist
         - Made an apt for Aug. 19, notified VA.
         - Never heard from Choice as of today.

    Conclusion: Of all the vets (and Dr. offices) I have talked to here 
in AK, not one had good things to say. Alaska had a good system. Deal = 
little wait/able to get info.

    The Chairman. Thank you. I can tell you, from the letters, 
calls, and the testimony we have seen over the last few days, 
this is a very, very common story, which is why we are here 
tonight: to fix this.
    Mr. Watts, again, thank you, sir, for your service as the 
commander for the VFW for the entire State of Alaska, for your 
participation yesterday, and for your willingness to testify in 
a hearing this evening. The floor is yours, sir.

   STATEMENT OF WALTER W. WATTS, JR., COMMANDER, VETERANS OF 
                 FOREIGN WARS, STATE OF ALASKA

    Mr. Watts. Thank you, Senator Sullivan. My name, for the 
record, is Walter W. Watts, Jr., and I am the current commander 
of the Veterans of Foreign Wars for the State of Alaska. I will 
not be speaking as the commander for over 7,000 veterans that 
are associated with our department, only because I just took 
office in the middle of July. I have not visited all 23 posts. 
I am talking from personal experience, first-hand experience, 
dealing with the Choice program.
    Choice. I wish it were a choice, and I will tell you why.
    I have been seeing a rheumatologist basically since 1998 
when I got out of the Army, retiring as a Sergeant Major. A 
former State employee, I worked as a vet rep. My title was 
Disabled Vet Outreach Program Specialist. I have had nothing 
but good service. Before the VA had a rheumatologist down at 
the Anchorage center, they used to send me down to see Dr. Tan. 
Dr. Sky was my rheumatologist at the VA center. She is no 
longer there.
    During this entire process, approximately every 3 or maybe 
4 months, depending on what the schedule was and how often a 
rheumatologist needed to see me, they would notify the 
Integrated Care folks. The Integrated Care folks would contact 
me and say, ``Walter, you are due for your follow-up with 
rheumatology.'' They would say, ``What is a good date?'' I 
would give them a good date, that information, and, boom, it 
worked. Not a hiccup. The only hiccup was if for some reason 
the phone system did not transfer down to Chet in travel, so I 
could get my flight down; that kind of stuff.
    In the middle of May, the nurse called me and said, 
``Walter, we have talked to Integrated Care and they should be 
calling you.'' Integrated Care here in Anchorage called me and 
said, ``Hey, we are going to get back with you to schedule an 
appointment.'' That worked for me and I said that the only 
thing is that it needs to be around 10 o'clock in the morning. 
``By the way, we are going to try to work with this new 
rheumatologist you have in Fairbanks.'' I said I do not have a 
problem with that.
    Well, 3 days went by and I get a phone call, thinking 
everything is set up because he is a new doctor to the system. 
They were in a panic. ``Walter, we are sorry. You have to call 
this 699-whatever Choice number and opt in to Choice.'' And I 
am like, if it is Choice, why do I have to opt in? ``Because we 
do not have any money. They took all of our money. It is all 
gone.''
    I thought about it a couple days. I called the number and 
finally got through after waiting a long time and told them 
what my name was, gave them my information as far as my last 
four, date of birth, etc.
    They asked me for the Choice card. I had gotten three of 
them, sir. In the process of getting them from last fall, I 
moved. They are downstairs in the office in a box someplace, 
and they said, ``Well, based on what you have given us, we are 
going to have to switch you over to the nurse line and they 
will start a case for you.'' That went on, that went on, that 
went on. I made multiple phone calls. I called their office and 
they said, ``Our system is down. It will be up in about 2 
hours.'' I called back, 2.5 hours later, the system is still 
down. I give them my name, give them my phone number and say, 
when the system comes up, could you please call me?
    I did not hear from the Choice program until I went to our 
Congressman Don Young's office in Fairbanks and filed a 
congressional inquiry. Now all of a sudden, everybody and his 
brother is trying to call me. I do not think I have to go to a 
Congressman to get someone who is supposed to be out there to 
help me as a veteran. Having served 27 years and did what I had 
to do, now I have to go to a Congressman to get something done?
    I do not think that you or Congressman Young or Senator 
Murkowski should be the appointment makers for all of us 
veterans here in Alaska. It shouldn't happen, OK?
    I have information, unfortunately, it came out last weekend 
garbled in the email, from Congressman Young's office on my 
follow-up and what I need to get done.
    Having gone through that, as I said, I have gotten all 
kinds of phone calls. I had troubles with my vehicle last week 
when I was down here. I finally got back. I told them, I will 
contact you and let you know if I am going to go with this 
doctor in Fairbanks, because they were not sure. They said they 
made multiple calls and all this stuff to him. I said I went by 
his office and picked up a packet. I have that filled out. I 
just have to find time. Of course, yesterday, I was at the 
session in Fairbanks.
    Why do we as veterans have to go through contacting our 
legislative group to get an appointment? Our system, I won't 
say it was perfect, but it was damn close before Choice came 
about. Why? Because you had to ``schedule'' an appointment, the 
nurse would call me up and say, ``Walter, I am getting in touch 
with Integrated Care. They should be getting in touch with you 
tomorrow, at the worst, the next day, because it is like 3 
o'clock in the afternoon.'' They will schedule your appointment 
as soon as you get off the phone, call down to travel. You go 
to travel.
    Listening to the people at the VA here in Alaska, because I 
am also a tribal vet rep. Our VA here has been recognized for 
the health care consortiums for those veterans who are out in 
rural Alaska that have to go to native health care. It is a 
great program. I have not personally been out lately, but I 
plan on going to Bethel and other places to visit those 
facilities, visit those VFW posts there. I will talk to the 
veterans who are there and see if anything has changed.
    Because the programs that we had in place worked great. Now 
you have somebody sitting in the lower 48 that does not have a 
clue. When you do finally get through to them and they start 
looking at your stuff, they want to talk to you about how the 
weather is in Alaska, what Alaska is like, it has always been 
on their bucket list. That is not what I want to hear, 
personally. I want you to take care of my issues.
    Now, they are jumping all over me to call them back, and I 
did do that not only yesterday after the session in Fairbanks, 
but I called them and we have just been missing each other, as 
far as the follow-up.
    Why did we have to change the Choice program, which is not 
a choice? It is not a choice for me or any of these other 
veterans sitting here. What we had worked. Why should we do 
that?
    The other side of it, and this is from a personal side, is 
payment. Right here, sir, I have approximately $15,000 worth of 
bills from last September when I had back surgery. The doctor 
got paid. Everybody got paid, but the top one is from the 
hospital. They are not beating me up like some of the other 
veterans I know personally who have things going into 
collection and all these other kinds of things. This is what is 
happening to me. I have $13,000 here.
    Well, guess what? After my 5 September surgery, everything 
seemed to be going great. I got an infection in that procedure. 
I had to go back in, in October. Well, during the recovery 
time, I had a PICC line in me. My wife was coming home every 
day, in the morning getting up before she went to work to give 
me my antibiotics, coming home for lunch, doing the same thing 
in the evening. I had a home health care provider. They had to 
do weekly lab tests and all that.
    Here is the other half of those bills, the other part of 
those bills.
    Why do we as a veteran get things that were preauthorized, 
preapproved, have to go through getting things like this in the 
mail? Why do we have to face companies, whether it is a health 
care provider or another service that was preapproved and have 
to go back to deal with that provider, so that they can get 
paid? My provider at this point still has not been paid. I 
would like to provide that to you or provide that to the VA 
group that is here. It is totally up to you.
    Why can't we go back to what we had, sir? Why can't we, as 
Alaskans, deal with what we previously had, because it worked 
for us? We don't care about the lower 48, the rest of the 
folks. They can come up with their own plan. Our plan worked 
for us, so why screw with something that isn't broken? It is 
kind of like in the Army. If it's not broke, don't fix it. Ours 
wasn't broke.

    The Chairman. Mr. Watts, thank you very much for your 
testimony.
    Mr. Watts. Thank you, sir.
    The Chairman. Thank you for your testimony yesterday.
    Listen, there are obviously some common themes here. There 
are common themes that we heard on the Kenai Peninsula in 
Fairbanks. There is frustration. There are long wait times. I 
think Dr. Shulkin and his team should be commended.
    There is also the idea that the local VA, whether it was in 
Fairbanks, whether it was here in Anchorage, whether it was on 
the Kenai Peninsula, was viewed by almost all of the veterans 
as being very responsive, very proactive. That has changed 
because, in many ways, the local control has been lost.
    I know we want to keep to our schedule here, but your 
testimony was very important. I am going to ask just a few 
question to follow up on some of the testimony here.
    I do want to get to this issue of the sense from all of 
you, if you can comment briefly, where we have gone from local 
control to elsewhere. Dr. Shulkin and I met with some of the 
folks at Integrated Care today, who are also frustrated because 
it now appears that the scheduling, the appointments, the 
approvals, the authorizations, are not occurring locally 
anymore. They are coming from Texas. They are coming from 
Louisiana. They are coming from places that, as Mr. Watts 
mentioned, are not at all familiar with our State.
    How do you see that as impacting both the wait times and 
the morale of the veteran in Alaska on the other end of the 
phone? Anyone?
    Mr. Bowen. Well, I know, personally, every day I get a 
phone call from someone who has a bill like this, and they have 
called that number in Portland hundreds and hundreds of times 
only to get nowhere.
    When they decentralized everything out of the facilities 
here in Alaska, we do not have anybody to touch. We used to be 
able to just go across the street and say, ``We have an issue 
with this veteran. Can you please help us?'' The local VA was 
totally responsive and able to provide them the health care 
that they needed, whether it was an appointment or whether it 
was bills getting paid. I don't know how many times emergency 
room visit issues have been taken over to the local VA and were 
resolved in-house.
    Now even I am confused who outside of the VA, outside of 
Alaska, is responsible for the bill.
    The Chairman. Just for the record, you are the premier VA 
official in the State of Alaska, are you not?
    Mr. Bowen. I do not know if I would say that.
    The Chairman. I would.
    Mr. Bowen. I thought I was doing pretty good until the 
Choice program came on, and now I am trying to scramble and 
find that magic button to touch to try to help.
    The Chairman. Mr. Bowen, if you are confused, the average 
staff sergeant getting out of the Marine Corps who is looking 
for benefits in Alaska and trying to understand the system, do 
you think he is confused?
    Mr. Bowen. I think that they are way in the dark. At least 
I can find someone in the chain somewhere who will point me in 
the right direction.
    The problem we have is our everyday veteran who is trying 
to seek health care, they just do not have a chance to resolve 
these issues.
    The Chairman. Or the time. We heard stories of veterans on 
the phone for 5 and 6 hours a day. A day.
    You know, Mr. Watts, you make a good point. I think Senator 
Murkowski, Congressman Young, my office, certainly, we are 
working hard to take care of our veterans, to undertake 
thorough constituent service. That is part of our job. We love 
to do it. As you mentioned, and it came up in the last two 
sessions, it should not take calling your Senator to get an 
appointment at as a veteran. That came up time and time again.
    Again, we are happy to help, but that is not what you want 
in terms of service. I think that is a frustration.
    Can I ask you, Mr. Bowen, can you just provide a little bit 
more detail on the unique programs that were working in Alaska: 
the DOD/VA joint venture agreement; the Care Closer to Home 
agreement; and the VA Alaska Native Healthcare partnership 
agreements. How these were working, and yet how the funding ran 
out? We have, as you mentioned, $127 million. What is going to 
happen on 1 October if this is not addressed; and how your 
recommendation, which I think is a very, very valid one: that 
until we have this issue thoroughly nailed down and addressed, 
that we should not be moving away from those kinds of programs 
to Choice when we know that is not ready for prime time, if it 
ever will be in Alaska.
    Can you talk about that again, and what the $127 million 
means, how you got that number, and why you think that is a 
good investment for good health care for Alaska's veterans, why 
it's a pretty good bang for the buck?
    Mr. Bowen. With the programs that we currently have, we 
will just use it like they have not gone away. With the Care 
Closer to Home, which is a program within the VA itself where 
they went out and actually purchased care at the local clinics 
and local doctors facilities that allowed veterans to be 
treated there, the next thing that was done is that we entered 
into 26 sharing agreements with the Alaska Native Healthcare 
System. With those 26----
    The Chairman. What does that mean for an average veteran?
    Mr. Bowen. What it means for a veteran, the best way to 
explain it, and I love referring to Emmonak because that is 
where the idea actually started. Out in Emmonak there was a 
gentleman trying to get back to the VA in Anchorage for a blood 
test. It took him 4 days to get back for a blood test. He spent 
2 days on the ground and then it took him 4 days to get back 
home.
    The VA had to pay for this huge amount of travel just for 
this person to do a simple blood test. If he just would have 
gone to his local clinic, which was in Emmonak, he could have 
had the blood test done. The blood could have been shipped to 
Anchorage, and there would have been not 8 days or actually 10 
days expended.
    The Chairman. So, more convenient for the vet and saves the 
VA boatloads of money.
    Mr. Bowen. Lots of money in travel. It allows the veteran 
to get that critical care instantaneously at home.
    It does not matter if you go to Alakanuk or one of the 
outlying communities where they have clinics where you can get 
your blood pressure pills and you can get continuity of care 
throughout the year. Even if you have to come into the VA to 
have your physicals, you are still getting back care within the 
Alaska Native Healthcare System, whether you are native or non-
native, throughout the State.
    What that did is it opened up access to care for our 
veterans like they had never had before. Now, it also did one 
other thing, because our veterans could only travel back to the 
VA on the expense of the VA if they are 30 percent or greater 
disabled or if the care is for something that happened while 
they were in the service. We have a lot of veterans out there 
that do not have a disability. They are just in the normal VA 
care system priority group 7 or priority group 8 that are 
seeking care within the VA system, which is a benefit they have 
earned. If they want to come into the VA, they have to pay for 
it themselves.
    Opening up the Alaska Native Healthcare System and the Care 
Closer to Home program allowed our veterans to receive care at 
home. They did not have to travel anywhere.
    Now, all of us know in Alaska that we do have to travel 
sometimes for specialty care. I mean, it is just the way it is, 
because of the limitations we have across the State. So, that 
is what those two programs did for us.
    PC3, on the other hand, was another contract vehicle that 
was coming in place which was another network of care outside 
of the Native Healthcare System, which allows our veterans to 
be treated in the Kenai Peninsula Hospital and the Ketchikan 
facilities.
    Looking at the different facilities we have throughout the 
State, it gave us a robust vehicle, whether it be Care Closer 
to Home that was purchased through the VA itself, PC3 that was 
purchased under a contract vehicle, or whether it was done 
through the Alaska Native Healthcare System.
    The Chairman. What happened to those programs when the 
Choice Act was implemented?
    Mr. Bowen. The Choice Act did not do anything to those 
programs. But, what happened after this was when all of the 
funding in the lower 48 was used to go out and purchase Care 
Closer to Home across the lower 48 to fix their problems, all 
of a sudden the VA went from $5 billion in purchased care to $9 
billion in purchased care. That meant Alaska lost all of its 
authority to purchase care within the State.
    The Chairman. How do we fix that?
    Mr. Bowen. How we fix it is that we add a line item within 
the VA budget that says that $127 million stays within Alaska 
within these three different programs. That way, if the lower 
48 decide to spend $9 billion in purchased care, which is 
already directed by Congress to be used specifically for this, 
VA will not be able to pull it out and use it for another 
shortfall within their budget.
    The Chairman. Let me ask a final question.
    Again, I really appreciate this panel's testimony and 
relaying your experiences. I think it gives a good flavor. This 
is the flavor that we have been seeing--the frustration, the 
time, the sense of why did we fix a system that was already 
working well?
    As you mentioned, Mr. Watts, it is not perfect, but it was 
certainly better than what we have presently.
    You have some senior officials that I am very, very 
appreciative have come all the way from Washington, DC, for 
this hearing, and we have them in front of all of us. This is 
an official Veterans' Affairs Committee hearing for the U.S. 
Senate.
    In conclusion, if each of you had a magic wand to fix this, 
if you could, briefly, what would your resolution be?
    Again, you can be as complex or as simple as you like on 
this. I would like to hear from each of you what you would do, 
what you would recommend to the witnesses on the upcoming panel 
to address what I believe everybody, including the next panel, 
agrees has been a fiasco for our State?
    Mr. Bowen. I guess I will start. I have the mic.
    I would fully fund the systems that we currently have that 
were being utilized. I would fund them at the amount we need to 
make them work.
    The Chairman. What was that amount again?
    Mr. Bowen. $127 million.
    Then, on top of that I would exempt Alaska from the Choice 
program more so on the basis that it can never be the number 1 
program again. If anything else ever happened, it needs to be 
where it needs to be. It needs to be a choice, just like the 
word says. The veterans should have the choice to use it or not 
to use it.
    What happened to our veterans is that it was not a choice. 
They had to use it, which they got caught in the ramp-up of a 
new system, and that really was unfair.
    I think fully funding the system would resolve any future 
issues that we have.
    The Chairman. Great.
    Mr. Joslin?
    Mr. Joslin. Thank you, sir.
    I, too, concur. I think the State of Alaska needs to be 
exempt from the Choice program. We need to take care if not 
directly back to the Integrated Care team at the VA, we need to 
look at utilizing case managers, nurse case managers or care 
managers, and not schedulers. There has to be a focus on 
continuity of care and the continuum of care, as was addressed 
by Ms. Williams.
    Just scheduling a VA patient wherever does not work. We 
took a system where care was directed for them and we created a 
system where they had to choose their care. For normal people 
who work in a health care system, navigating the health care 
environment can be difficult. If you take a VA patient that 
might have some behavioral health or mental health concerns and 
multiple complex medical issues as well and ask them to 
navigate a health care system that as a senior health care 
manager I have a problem navigating at times, it is not going 
to work out well.
    We have to get the program back. I agree Choice needs to be 
a safety net, where it needs to be there, but it needs an 
exemption clause, not the primary focus of care.
    The Chairman. Great. Thank you.
    Ms. Williams?
    Ms. Williams. I think this panel is going to be unanimous 
that we need to be exempt from Choice. It obviously is not 
working up here. I do not know about the lower 48.
    I also think that we should take a look at the system and 
see other areas we can cut finances that are being wasted and 
put it into the care that we need in Alaska.
    The Chairman. Great. Thank you.
    Mr. Watts, the final word?
    Mr. Watts. A magic wand.
    The Chairman. A magic wand.
    Mr. Watts. A magic wand. Go back to what we had before that 
mid-May--you guys know what that date was--before that. Get 
Alaskans back in here doing what they do well. Put more people 
in Integrated Care at the Anchorage VA facility, because that 
is what works for Alaska. That cookie-cutter formula does not 
work here.
    Let's keep it simple, do what we were doing well, and go 
back to doing it.
    The Chairman. Great.
    Well, listen, I really appreciate and want to thank the 
panel again for your dedication, for your service, for all of 
you as veterans, for your continued service--all of you--to our 
veterans, and for your testimony here at this hearing. I think 
it was very, very informative, and it is, certainly, going to 
help get us on the pathway to where we need to be, which is 
taking care of our veterans and doing a better job here in 
Alaska on that. Thank you very much.
    I would now invite the second panel to please come up to 
the podium, and we will begin the second panel in a matter of 
minutes. Thank you very much. [Pause.]
    Great. I want to continue our hearing.
    I want to thank, once again, the members of the second 
panel, Dr. David Shulkin, in particular, who is the Under 
Secretary for Health at the VA.
    Dr. Shulkin, as I mentioned earlier, has a very extensive 
resume as a medical physician, as a hospital administrator, and 
is someone in his confirmation hearing who stated pointblank he 
wanted to serve in the VA in a difficult position like this 
simply because he wanted to serve our veterans. That was it, 
public service. I very much appreciate him wanting to take on a 
tough role and very much appreciate him coming to Alaska. I 
think we have all learned a lot together, and we want to work 
together on these issues.
    Dr. Andrea Buck, who is associate director for medical 
consultation review in the Office of Health Care Inspections at 
the Office of Inspector General at the VA, and Mr. David 
McIntyre, who is the President and Chief Executive officer of 
TriWest.
    Mr. McIntyre, I also appreciate you attending the listening 
session in Fairbanks yesterday. You got a lot of the flavor of 
what the significant concerns are with the TriWest program.
    Without further ado, I would ask for the opening 
statements. I would like to keep those within 5 minutes so we 
can get to questions. Again, I very much appreciate the panel 
coming here this evening.
    Dr. Shulkin?

   STATEMENT OF DAVID J. SHULKIN, M.D., UNDER SECRETARY FOR 
  HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY 
   THOMAS LYNCH, ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH 
CLINICAL OPERATIONS; LARRY CARROLL, NETWORK DIRECTOR, VISN 20; 
 AND LINDA BOYLE, ACTING DIRECTOR, ALASKA VA HEALTHCARE SYSTEM

    Dr. Shulkin. Good evening, Senator Sullivan. Thank you for 
the opportunity to appear before you to discuss the Department 
of Veterans Affairs health care and benefits for Alaska 
veterans and their families. I also want to thank you for your 
invitation to visit Alaska to see the VA healthcare system here 
firsthand.
    With me today to my left is Dr. Thomas Lynch, who is the 
Assistant Deputy Under Secretary for Healthcare Clinical 
Operations based in D.C. I am also accompanied behind me by Mr. 
Larry Carroll, who is director of the VA's Northwest network, 
and Dr. Linda Boyle right behind me, who is the acting director 
of the Alaska VA Healthcare System. Also with us today is Dr. 
Cynthia Joe, who is the chief of staff of the Alaska VA 
Healthcare System.
    I really want to recognize the Alaska veterans who are here 
in attendance. Thank you to you for your service. You are the 
reason that the VA opens its doors every day, and we want to 
ensure that you have the highest quality care and timely care.
    I want to thank the first panel for sharing their 
experiences. It is very helpful, and we will get back to how we 
think we can help fix the situation.
    Senator Sullivan, I also want to particularly thank you for 
your leadership and support for changing the 40-mile rule, the 
desistance calculation eligibility rule, a change that not only 
benefited Alaska veterans but those veterans across the country 
who are eligible for the Choice program.
    I think most people know, 2 weeks ago, Secretary McDonald 
traveled across Alaska to meet personally with Alaska veterans, 
tribal leaders, and our partners across the State. Right after 
he got back to Washington, the Secretary and I met so he could 
talk to me about his perspectives before I came to Alaska 
myself.
    I just want to assure you that we heard you. We hear your 
message loud and clear that the Choice system is not working 
for you. The VA has to continue to find ways to make this 
better, to improve access, and to coordinate care for veterans 
not only within VA itself but within our community partners.
    I now know firsthand, thanks to the invitation here, Alaska 
has some very unique challenges. It is different from the lower 
48, and we have to work together to overcome these challenges.
    As the Senator said, today marks my 49th day as the Under 
Secretary of Health, so I can bring a fresh set of eyes and the 
private sector physician perspective to the challenges that are 
facing veterans here in Alaska.
    Our listening sessions in Fairbanks and Kenai yesterday 
underscored the need to maintain our current Department of 
Defense and tribal agreements, as well as address the issues we 
are hearing about today in the Veterans Choice Program.
    The messages that we heard in these listening sessions were 
that the veterans were extremely satisfied with their local VA 
care, but the challenges with the Choice program have been 
overwhelming. We heard that from the first panel.
    The message was also clear that veterans felt that we 
needed our local VAs to have more local control and autonomy 
and less centralized control and authority from organizations 
like in Washington, D.C.
    Based upon the feedback that we heard, I want to share with 
you six principles that are going to guide our decisionmaking 
in fixing the problems here in Alaska.
    Number 1, we plan to honor our agreements to ensure 
continuity of care for veterans with the Department of Defense, 
the Indian Health Service, and the tribal organizations. VA's 
relationship with Joint Base Elmendorf (JBER) is one of 11 
nationwide that is a joint venture. We all know that JBER was 
recognized as the best inpatient facility patient safety 
program in the Pacific Air Forces for 2014.
    Alaska has led the Nation in a developing VA sharing 
agreements with native health care entities with 26 of those 
agreements currently in place.
    Number 2, we will continue to build the Choice network with 
willing providers and to improve veteran awareness and 
understanding. VA has held outreach sessions for Choice vendors 
in Anchorage, Mat-Su, Kenai, Fairbanks, Juneau, and Ketchikan 
to explain and encourage vendor participation in the Choice 
program. The VA has held numerous one-on-one vendor office 
visits to assist new Choice providers with signing on and 
navigating the Choice program.
    Number 3, we will work for contractual arrangements with 
TriWest that will allow the VA staff to be directly involved in 
scheduling and appointment authorizations. We're working with 
TriWest to explore options to modify the contract where the VA 
could have the primary role in scheduling the coordination of 
care. Those functions would be brought back into the VA to 
simplify eligibility authorization and referral to the TPA for 
veterans that have care in the community.
    Number 4, we are pursuing policies, regulatory and 
legislative authority, to allow for maximum flexibility in 
community care funding. VA recognizes and understands the 
Department of Defense and some tribal communities may wish to 
maintain their current arrangements and not join Choice. The VA 
has urged Congress to pass legislation that would enable us to 
reconcile and merge the many different non-VA programs into a 
single community program and budgetary fund. Having such a 
consolidated fund for VA care in the community would improve 
the understanding of care when VA authorizes and pays for care 
in the community. The VA is submitting a plan to Congress to 
accomplish this by November 1.
    In addition to the budget and single appropriation for care 
in the community, we are working with Congress to also 
eliminate administrative and bureaucratic issues with 
authorization or referral for veterans for care in the 
community. We urge Congress to give us this flexibility to 
refer veterans to our DOD, tribal, and other providers in the 
community, depending upon the unique needs of the veterans, the 
State, and local communities, such as here in Alaska.
    Senator Sullivan, we need you and your colleagues' support 
to accomplish this.
    Fifth, we want to explore joint ventures in innovative 
models between VA and community partners to find better ways to 
serve Alaska veterans. Given Alaska's large geographic and 
significant travel challenges, VA must work diligently with 
Federal, State, tribal, and local community partners to expand 
their care in the community. The VA realizes that without each 
of our community partners, we could not continue to provide the 
high-quality care and enhanced care for Alaska veterans. The VA 
is committed to working collaboratively with all of our 
community partners to develop joint solutions here in Alaska.
    Finally, number 6, is recruitment and retention. It is 
critical that we increase our efforts to recruit providers to 
come to Alaska and to be very proactive in that recruitment. It 
is equally critical that we work to retain those who choose to 
work in our system here in Alaska.
    In conclusion, our objective is to always provide veterans 
with timely and high-quality care with the utmost dignity, 
respect, and excellence. We recognize that we have had 
challenges doing that in the past couple months. I understand 
that Alaska offers some unique challenges to providing that 
care, but I do believe that together we can overcome those 
challenges.
    Senator Sullivan, this concludes my testimony. My 
colleagues and I are prepared to answer any questions that you 
may have.
    [The prepared statement of Dr. Shulkin follows:]
Prepared Statement of David Shulkin, M.D., Under Secretary for Health, 
  Veterans Health Administration, U.S. Department of Veterans Affairs
    Good Afternoon Senator Sullivan. Thank you for the opportunity to 
appear before you to discuss Department of Veterans Affairs (VA) health 
care and benefits for Alaska Veterans, and their families. With me 
today at the witness table is Dr. Thomas Lynch, Assistant Deputy Under 
Secretary for Health Clinical Operations. I'm also accompanied by Larry 
Carroll, Director of VA's Northwest Network, and Dr. Linda Boyle, 
Acting Director of the Alaska VA Healthcare System.
    Today, I will briefly review the current facilities and services of 
the Alaska VA Healthcare System (AVAHS) which will also include 
information about enrolled Veterans and current users, tele-health and 
training initiatives, agreements with Federal and Tribal healthcare 
systems, the Veterans Choice Program and the delivery of non-medical 
benefits and services.
          alaska va healthcare system facilities and services
    The Alaska VA Healthcare System provides health care to eligible 
Alaska Veterans through an integrated delivery system that includes VA 
clinical care sites and care provided through a VA/DOD Health Care 
Resources Sharing Agreement and 26 Direct Care Services Reimbursement 
Agreements with Alaska Tribal Health Programs. The Alaska VA Healthcare 
System's Joint Commission-accredited facilities serve Veterans 
throughout Alaska. The parent facility is located in Anchorage, Alaska 
and is attached to the 673d Medical Group (MDG), Joint Base Elmendorf-
Richardson (JBER) via a connecting corridor. There are three VA 
Community-Based Outpatient Clinics (CBOC), which are located in 
Fairbanks (358 miles north of Anchorage), Kenai (158 miles south of 
Anchorage), and Wasilla (Mat-Su) (41 miles north of Anchorage). The 
Fairbanks VA CBOC is located in the Bassett Army Community Hospital 
under a VA/DOD Health Care Resources Sharing Agreement. In addition, 
there are two VA Outreach Clinics. One is located in Homer and is an 
extension of the Kenai CBOC. The Homer clinic serves Veterans twice a 
week at the South Peninsula Hospital under a contract for space and 
ancillary services. The second is located in Juneau (569 miles from 
Anchorage). The Juneau VA Outreach Clinic operates under a lease in the 
Juneau Federal Building, leveraging efficiencies of space and 
operations with the U.S. Coast Guard. The cities of Anchorage, 
Fairbanks, Wasilla, and Soldotna are also home to VA Readjustment 
Counseling Centers, or Vet Centers, which provide counseling, 
psychosocial support, and outreach to Veterans and their families.
    AVAHS provides or contracts for a comprehensive array of health 
care services. It directly provides primary care, including preventive 
services and health screenings, and mental health services at all 
locations. Inpatient care is provided at JBER as well as through 
contracts with community medical facilities. AVAHS provides specialty 
care in General Surgery, Podiatry, Orthopedics, Cardiology, and 
Optometry. Urology and Opthalmology are provided at JBER. The Anchorage 
facility also has a Dental Clinic, Physical Therapy and Occupational 
Therapy clinic and an Audiology Clinic. Audiologists travel to VA CBOCs 
and Coast Guard clinics in Southeast Alaska to provide care to 
Veterans. The audiologists have also traveled to rural areas of Alaska, 
such as Bethel, Unalaska and Metlakatla, to provide direct patient 
care. AVAHS also has an active Home-Based Primary Care program serving 
89 Veterans in their homes within a 20-mile radius of the Anchorage 
facility.
    AVAHS also offers a comprehensive continuum of care for homeless 
Veterans. Inpatient mental health services are provided through 
contracts with community psychiatric facilities and hospitals, as well 
as specialized programs at VA facilities in the Lower 48. Additionally, 
AVAHS has a 50-bed domiciliary located in midtown Anchorage. There is a 
Fisher House located on Air Force property that serves eligible 
servicemembers and Veterans. AVAHS contracts for nursing home care and 
other non-institutional care programs which include adult day care, 
respite, hospice, homemaker/home health aide, and skilled nursing.
                    enrolled veterans/current users
    As of Fiscal Year (FY) 2015, there are 73,276 Veterans residing in 
Alaska (VSSC Enrollment and Vet Pop Projections Report). With dedicated 
outreach efforts by AVAHS, enrollees increased from 22,000 in FY 2002 
to 32,104 as of August 2015 (VSSC Current Enrollment Cube), a 45.9% 
increase; 44% of Alaska Veterans are now enrolled in VA Health Care. In 
the same time period, Veteran users of VA health care benefits have 
increased from 12,262 in FY 2002 to 18,741, a 52.8% increase. Over 88 
percent of enrolled Alaska Veterans live in a borough with a VA 
clinical presence. With the addition of care provided through 26 Direct 
Care Services Reimbursement Agreements with Alaska Tribal Health 
Programs. Alaska Veterans enjoy excellent geographic access to VA or 
VA-authorized care. While there has been progress, we know that there 
are still opportunities to increase access and utilization as indicated 
by the following chart.

 
------------------------------------------------------------------------
                                     Vet Pop     Enrollees      Users
------------------------------------------------------------------------
(02013)  Aleutians East, AK......       151           32           13
(02016)  Aleutians West, AK......       345           49           16
(02020)  Anchorage, AK...........    30,155       14,984        8,974
(02050)  Bethel, AK..............       994          310           93
(02060)  Bristol Bay, AK.........       114           32           16
(02068)  Denali, AK..............       233           84           41
(02070)  Dillingham, AK..........       295           99           38
(02090)  Fairbanks North Star, AK    12,664        4,662        2,680
(02100)  Haines, AK..............       282           90           45
(02105)  Hoonah-Angoon, AK.......       197           83           39
(02110)  Juneau, AK..............     2,256          928          469
(02122)  Kenai Peninsula, AK.....     5,522        2,592        1,736
(02130)  Ketchikan Gateway, AK...     1,457          388          170
(02150)  Kodiak Island, AK.......     1,363          386          186
(02164)  Lake and Peninsula, AK..       117           40           13
(02170)  Matanuska-Susitna, AK...    10,886        5,209        3,257
(02180)  Nome, AK................       671          126           35
(02185)  North Slope, AK.........       346           85           33
(02188)  Northwest Arctic, AK....       459           92           21
(02195)  Petersburg, AK..........       402          106           46
(02198)  Prince of Wales-Hyder,         541          209          103
 AK..............................
(02220)  Sitka, AK...............       786          242          110
(02230)  Skagway, AK.............        85           24           13
(02240)  Southeast Fairbanks, AK.       747          446          233
(02261)  Valdez-Cordova, AK......     1,076          376          199
(02270)  Wade Hampton, AK........       278          107           26
(02275)  Wrangell, AK............       266          114           48
(02282)  Yakutat, AK.............        78           17            7
(02290)  Yukon-Koyukuk, AK.......       510          192           81
                                  --------------------------------------
                                     73,276       32,104       18,741
------------------------------------------------------------------------

                             mat-su va cboc
    On July 7, 2015, VA Office of Inspector General (OIG) released its 
report, ``Healthcare Inspection: Scheduling, Staffing, and Quality of 
Care Concerns at the Alaska VA Healthcare System Anchorage, Alaska.'' 
The investigation was conducted to assess the merit of allegations 
regarding provider availability, workload, access, quality of care and 
security, and scheduling practices.
    The investigation substantiated that Mat-Su CBOC had a period of 
inadequate staffing, which resulted in poor access to care for some 
patients, which in turn resulted in poor quality of care. The 
investigation did not substantiate the allegation of security issues at 
Mat-Su CBOC. The OIG found that there had been problems with scheduling 
practices in 2008, but there were none at the time of the 
investigation.
    VA appreciates this review by the OIG and the opportunity to 
improve the service we provide to our Veterans. VHA is committed to 
correcting the issues in the report. Action plans have been implemented 
to address the recommendations, with all actions expected to be 
completed by December 31, 2015. AVAHS leadership remains committed to 
improving care for our Veterans in Alaska and will continue to keep 
Veterans and stakeholders informed of our progress as we work on 
improving service, access and overall quality of care.
                              initiatives
    Tele Behavioral Health--AVAHS, under the auspices of the Alaska 
Tribal Health Program (ATHP) Direct Care Services Reimbursement 
Agreement with Southeast Alaska Regional Health Consortium in Sitka, 
AK, implemented a Tele-Behavioral Health project to provide one half-
day per week treatment for Veterans with Post-traumatic Stress Disorder 
(PTSD). This initiative, approved through the Veterans Health 
Administration (VHA) Office of Rural Health provides treatment via 
telemedicine by a VA provider located in Anchorage to Veterans who are 
present at Mount Edgecumb Hospital in Sitka. Since its start on 
August 8, 2013, the clinic has added another half day of care for Sitka 
and is expanding to include three more Southeast Alaska communities. 
The program will serve its first Veteran in Angoon by the end of FY 
2015 and will begin serving Kake and Hoonah in FY 2016.
    AVAHS has also initiated secure Clinical Video Telehealth into 
Veterans' homes. All AVAHS behavioral health providers have completed 
foundational training to expand secure Clinical Video Telehealth into 
the home. Four providers are actively providing this service to ten 
rural Veterans.
    Telehealth--AVAHS makes active use of several telehealth modalities 
in order to offer services to Veterans. Alaska Telehealth services 
include: Teledermatology, Teleretinal Imaging, Tele Behavioral Health, 
Tele Renal Transplant Evaluation, Tele Amputation Evaluation, and Tele 
Medication Management. Group Telehealth services include: Tele Diabetes 
Education, Tele Nutrition Education, TeleMOVE!, and Tele Behavioral 
Health.
    As of the third quarter FY 2015, over 2,300 Veterans have been 
served by AVAHS's Telehealth programs. New clinics, such as Tele 
Audiology and Tele Substance Use Disorder Group are being developed and 
will be operational in FY16.
    Tele Primary Care--AVAHS initiated a pilot Tele Primary Care Clinic 
on June 27, 2013. A primary care nurse practitioner located in Denver, 
Colorado held clinic twice per week providing care to Veterans in 
Alaska. The pilot was successful, and now has grown to four primary 
care clinics supported by providers in Colorado, Florida, Idaho, and 
California. These clinics currently have capacity to serve 2,380 
Veterans. In FY 2016 the program will expand from the main Anchorage 
facility to community based outpatient clinics located at Mat-Su and 
Fairbanks. These clinics will be supported by providers located in 
Boise and Anchorage adding an additional capacity for 1,500 Veterans. 
This program is leveraging technology to meet provider shortages.
    Rural Outreach Program--The Rural Outreach Program has continued to 
expand its outreach to rural communities with the support of funds from 
the VHA Office of Rural Health. Outreach has moved beyond the hub 
communities to the smaller villages, which include, but are not limited 
to, Cold Bay, King Cove, Mentasta Lake, Tok, Fort Yukon, Beaver, and 
Stevens Village. VA staff have visited between 24 to 30 communities per 
year for the past three fiscal years. Community-wide enrollment and 
benefits-outreach events, known as Stand Downs, for Veterans in rural 
areas have occurred in Juneau in 2012, Dillingham in 2013, Bethel in 
2014, Dutch Harbor/Unalaska Homer, Kotzebue, and Kenai in 2015, and 
will occur in Nome in September 2015.
    Tribal Veteran Representative (TVR) Program--The TVR program uses 
local community volunteers to assist VA in reaching out to Alaska 
Native Veterans. A TVR is an Alaska Native Veteran or recognized 
individual appointed by an Alaska Native Health Organization, Tribal 
Government, Tribal Council, or other Tribal entity to act as a liaison 
with local VA staff. The TVR is a volunteer, unless paid by the Alaska 
Native entity who selects the individual to represent them. 
Collaborative training is provided by VA health care and benefits 
staff. To date, 13 TVR training sessions have been conducted. In 2015, 
training was conducted at Dutch Harbor, Homer, Kotzebue and Kenai, and 
will be conducted in conjunction with the Stand Down event in Nome. 
AVAHS has trained 250 TVRs from 40 Alaska communities to date. This 
effort will continue next year and beyond, dependent on funding and 
budget for the Rural Health office.
    VA/DOD Health Care Resources Sharing Agreements and Direct Care 
Services Reimbursement Agreements--AVAHS's VA/DOD Health Care Resources 
Sharing Agreement with the 673d MDG JBER provides for services to 
eligible Veterans and DOD beneficiaries. The Alaska VA Healthcare 
System also maintains a VA/DOD Health Care Resources Sharing Agreement 
with Bassett Army Community Hospital, Fort Wainwright. The Juneau 
clinic and the U.S. Coast Guard in Juneau, Alaska are able to assist 
each other due to their proximity in the Federal building. In addition, 
AVAHS and the 673d MDG have had successful Joint Incentive Funds (JIF) 
projects for Enhanced Outpatient Diagnostic Services to integrate VA 
demand for Computed Tomography (CT)/Magnetic Resonance Imaging (MRI), 
establishment of a Sleep Lab, addition of a second MRI to increase 
access/capacity, establishment of a Pain Management Clinic, and 
Cardiology Services Enhancement for 2013/2014. The quality and level of 
service enabled by VA's health care resources sharing agreement with 
the 673d MDG, led 673 MDG to win ``Best Inpatient Facility Patient 
Safety Program in the Pacific Air Forces for Fiscal Year 2014,'' 
enhances and provides additional support for Alaska Veterans. In 
addition to the clinical JIF projects, the relationship results in 
significant efficiencies in the integrated warehouse and sterile 
processing departments. When VA determined to institute ISO 9001 
standards into the Sterile Processing Service (SPS), the integrated SPS 
located at the 673d MDG also incorporated ISO 9001 standards into their 
processes. The jointly staffed Intensive Care Unit offers tremendous 
capacity to Veterans that would not otherwise be available. In 
addition, the Air Force Emergency Department (ED) functions as the ED 
of choice for Anchorage bowl Veterans.
    Alaska Federal Health Care Partnership (AFHCP)--The AFHCP is a 
formal, voluntary, interagency relationship between DOD, Department of 
Homeland Security, Health and Human Services' Indian Health Service, 
VA, Alaska Native Tribal Health Consortium, and Alaska Native Medical 
Center working together to share and provide efficient delivery of 
healthcare education to combined audiences, as well as sharing 
information, talents, and experiences to improve patient care for all 
Federal beneficiaries throughout the State of Alaska.
    Direct Care Services Reimbursement Agreements with ATHPs--In 2012, 
VA signed 26 Direct Care Services Reimbursement Agreements with ATHPs 
to reimburse the ATHPs for direct care services they deliver to 
eligible Native and non-Native Veterans seen throughout Alaska. These 
are 5-year agreements, and have strengthened both VA and ATHP systems 
to increase access to care for Native and non-Native Veterans, 
particularly those in remote and rural areas served by ATHPs. The 
Alaska VA has purchased care for approximately 8,000 Veterans and paid 
over $13,000,000 in care since signing the agreements. Care received by 
Veterans living in rural communities is steadily increasing. When 
shortfalls due to provider staffing occurred, Southcentral Foundation 
in Wasilla began providing primary care to over 1100 Veterans. There 
are over 600 Veterans receiving primary care at Chief Andrew Isaac 
Clinic in Fairbanks Alaska, thereby providing access to care for 
Veterans living in areas where attracting providers has been 
challenging.
    Veterans Choice Program--The Veterans Choice Program is helping VA 
to meet the demand for Veterans' healthcare in the short-term. VA's 
goal is always to provide Veterans with timely and high-quality care 
with the utmost dignity, respect, and excellence. For the Veteran who 
needs care today, VA's goal will always be to provide timely access to 
clinically appropriate care in every case possible. However, as we have 
shared with staff for the Senate and House Committees' on Veterans 
Affairs, users of the Veterans Choice Program have identified aspects 
of the law that are challenging. We are working diligently to address 
these challenges and to turn them into opportunities to improve VA care 
and services.
    As of August 4, 2015, AVAHS had made 5,215 referrals for care 
through the Veterans Choice Program. Town Hall outreach sessions for 
community providers have been held in Anchorage, Mat-Su, Kenai, 
Fairbanks, Juneau and Ketchikan to explain the Veterans Choice Program 
and encourage provider participation in the Veterans Choice Program. 
Numerous one-on-one provider office visits have been conducted to 
assist individual office staff with signing on as Veterans Choice 
Program providers and with navigating the Veterans Choice Program. Town 
Hall outreach sessions for Veterans have also been held in Anchorage, 
Mat-Su, Kenai, Fairbanks, Juneau and Ketchikan to inform and assist 
Veterans with the Veterans Choice Program. AVAHS has grown their cadre 
of ``Choice Champions'' staff, specializing in the current information 
and processes of implementing the Veterans Choice Program, to include 
additional Anchorage VA staff and CBOC staff. This enables specific 
staff to develop and retain in-depth knowledge of the Veterans Choice 
Program to assist Veterans with specific concerns. Choice Champion 
staff has met with VA Alaska employees, engaging in information sharing 
and problem-solving regarding implementation of the Veterans Choice 
Program.
    To summarize, AVAHS continues to work to increase access to Alaska 
Veterans. The most significant accomplishments in the past two years 
have been AVAHS's outreach to rural Alaska as well as the Direct Care 
Services Reimbursement Agreements with ATHPs. A continued priority is 
to reach Veterans statewide to increase enrollment and access to VA 
services closer to where the Veteran resides. This can be provided 
either directly, through tele-health by VA staff, or through contracts 
or other agreements with medical facilities already located in their 
home communities.
                    veteran benefits administration
    Approximately 80 percent of Anchorage Regional Office (RO) 
employees are Veterans themselves. 35 employees work in the Veterans 
Service Center (VSC), and eight work in Vocational Rehabilitation and 
Employment (VR&E). The RO is currently onboarding two new Vocational 
Rehabilitation Counselors to support the two counselors currently 
overseeing the VR&E Integrated Disability Evaluation System (IDES) 
activities at Fort Wainwright and JBER.
    Employees at the Anchorage RO are extremely motivated and provide 
excellent service to Alaska Veterans and their families; nonetheless, 
they fully understand there is more work to be done as we work to 
eliminate the claims backlog.
                               conclusion
    In conclusion, AVAHS has continued to improve access and services 
to meet the needs of Veterans. We are committed to ensuring the best 
possible service is provided to Veterans, their families, and surviving 
spouses. We are happy to answer any questions you may have.

    The Chairman. Thank you, Dr. Shulkin. I appreciate that 
testimony. I appreciate you laying out those principles as a 
way forward. I think those are some things that we will be 
looking forward with you and other key stakeholders in all of 
this, to make that work.
    Dr. Buck.

 STATEMENT OF ANDREA C. BUCK, M.D., CHIEF OF STAFF, HEALTHCARE 
   OVERSIGHT INTEGRATION, OFFICE OF INSPECTOR GENERAL, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY SAMI O'NEILL, 
    DIRECTOR, SEATTLE, WA, OFFICE OF HEALTHCARE INSPECTIONS

    Dr. Buck. Senator Sullivan, thank you for the opportunity 
to speak before you today. It is an honor to do so and to 
address the unique needs of Alaskan veterans. I am accompanied 
by Ms. Sami O'Neill, our director from the Seattle office and 
the Office of Healthcare Inspections.
    We were asked to testify regarding our recent report on 
scheduling, staffing, and quality of care concerns at the 
Alaska VA Healthcare System. This work was done in response to 
a request from Senator Murkowski to look primarily at the 
access to care at the Wasilla clinic, some security concerns 
there, and access to urological services at that Alaska VA.
    While the challenges faced by Alaska veterans are unique, 
there is some common ground where you might find some of these 
problems anywhere where doctors are scarce and distances are 
long. It can be awfully hard to find enough good providers in 
these areas.
    It makes what you said today about the Veterans' Choice Act 
all the more important. There have to be effective community 
partnerships in those areas, because there simply are not 
otherwise enough doctors and nurses to go around.
    The Mat-Su VA clinic is an example of what those challenges 
can be like. The clinic opened in March 2009, and the VA was 
able to find a physician to staff it within 6 months. It found 
a second physician in 2011 to come work for the clinic. That 
physician remained until 2012 before leaving. That left the 
single remaining provider with 1,700 veterans to care for in 
the Mat-Su clinic, and that was at least that many veterans.
    As a result of that workload, the second provider left in 
May 2014. Between 2012 and 2014, there were 66 days in which 
there was no licensed independent practitioner at the clinic. 
It was left to nurses and other support personnel to attempt to 
care for the veteran needs at that clinic.
    The VA took steps to try to correct this problem. They 
tried to get locum tenens providers, temporary providers. They 
tried to get other providers to come in. They tried recruitment 
and retention efforts, and they contracted with Southcentral 
Foundation, a nonprofit native-owned health care organization.
    But it takes time to transition patients into a practice. 
They have to be able to take care of the patients they are 
already taking care of. It took some time to do that.
    This is about the impact of not having enough doctors and 
nurses in a clinic like that on care that is provided. That is 
what we looked at. We chose to look at 40 veterans who died 
between July 2013 and July 2014 while receiving care at that 
Mat-Su clinic. The reason we chose to look at those veterans is 
because we know that at the end of life in the months prior to 
death, that is when most people will consume most of the health 
care resources they consume during their entire lives.
    We chose to look at the sickest veterans to better 
understand what was the care like that they were receiving and 
were they able to access that care. We found nine veterans who 
had difficulty in accessing that care. We found that that 
resulted in quality of care concerns for seven of those nine 
veterans.
    As you said in your opening statement, sir, this is about 
the veterans, so we will share one story, although they are all 
detailed in the report, of a veteran that we described in that 
report.
    This was a veteran in his 70s with a history of melanoma. 
He needed a follow-up every 6 months from his dermatologist. 
After his cancer was removed, he came back to the Mat-Su clinic 
about 6 months later with shoulder pain. His cancer had been in 
his shoulder. He was sent to an orthopedic doctor who diagnosed 
a mechanical problem with his shoulder and injected it.
    A few weeks later, he called back, complaining of more 
shoulder pain. Again, there was not a follow-up appointment 
arranged with a dermatologist. He was instructed on how to take 
anti-inflammatories and other medications for his shoulder.
    A few months later, he returned to the clinic again for lab 
work. No provider saw him at that time. It was around the time 
that the second provider left the Mat-Su clinic. Again, he was 
not given a follow-up appointment with a dermatologist.
    One month later, he went to an emergency department and at 
that time was found to have metastatic cancer. He entered 
hospice and subsequently died.
    When we see problems like this, we want to understand why 
they happen. One is that it is hard to find doctors for these 
areas. Two is, how does a system not know or not be aware that 
these kinds of things are going on?
    We did identify in our report deficiencies in peer reviews, 
ongoing practice evaluations with physicians, and the flow of 
information to the leadership was impaired by cultural issues. 
If leadership is not receiving the honest, on-the-ground 
reports in an effective and timely manner, it impairs their 
ability to respond to crises like this.
    In the end, we made nine recommendations for improvement. 
We recommend improvements in recruitment and retention, in 
contingency planning so that there are plans in place. We know 
that providers will leave from time to time. We know that there 
will be episodes of short staffing. Contingency planning for 
that is very important, so there are not those delays.
    Care coordination, knowing how to coordinate care across 
the spectrum when you are dealing with specialists who are 
outside and inside the system.
    Finally, peer reviews, provider evaluations, improvements 
in the culture, and committee reporting at the facility.
    From our standpoint, our work is not done just because we 
made nine recommendations. We have just completed a combined 
assessment program review of the hospital, which is our program 
where we go out to all hospitals once every 3 years--I am 
sorry, not the hospital, the Anchorage community-based 
outpatient clinic (CBOC)--where we go out to all facilities 
like that once every 3 years to identify proactively any 
problems that might be occurring. We have planned follow-up 
work in the next 2 months in Fairbanks and in other areas in 
Alaska to address the ongoing and continuing care concerns that 
have surfaced with the Choice Act and other similar concerns.
    In addition, we have ongoing work on the Veterans Choice 
Program. As you know, the statute required that the Office of 
Inspector General (OIG) do oversight work after 75 percent of 
funds had been expended for the Choice program. As you heard 
today, if folks are not getting into the program, then those 
funds are not going to be expended for a while. In addition to 
that, we have actually started work to begin review of 
implementation of the program from the perspective of 
determining if the VA staff know enough about the program so 
that they themselves can provide veterans the information they 
need to be able to help veterans access the services. We have 
that planned as well.
    In the end, it serves us all well if the VA works well. We 
believe in the VA, just as the department and VHA does. We 
believe in its ability to provide unique services to the 
veterans.
    We need to support that, and we look forward to continuing 
oversight and helping the VA to identify where the problems are 
so that those can be addressed in a timely fashion.
    I am happy to answer any questions.
    [The prepared statement of Dr. Buck follows:]
    Prepared Statement of Andrea C. Buck, M.D., Chief of Staff For 
  Healthcare Oversight Integration, Office of Inspector General, U.S. 
                     Department of Veterans Affairs
    Mr. Chairman and Members of the Committee, Thank you for the 
opportunity to testify before the Committee today on veterans' access 
to care in Alaska and our recent report, Scheduling, Staffing, and 
Quality of Care Concerns at the Alaska VA Healthcare System, Anchorage, 
Alaska, which highlights the challenges some veterans have faced in 
receiving timely access to care in Alaska.\1\ I am accompanied by Ms. 
Sami O'Neill, Director of the Seattle, Washington, Office of Healthcare 
Inspections.
---------------------------------------------------------------------------
    \1\ http://www.va.gov/oig/pubs/VAOIG-14-04077-405.pdf, published 
July 7, 2015.
---------------------------------------------------------------------------
                               background
    Alaska has a chronic shortage of physician providers, ranking 17th 
lowest in the Nation in its physician-to-population ratio, with 2.05 
doctors per thousand residents compared to the national average of 2.38 
per thousand. Further, it is one of six states without an independent 
in-state medical school. Thus, it funds 20 state-supported ``seats'' at 
the University of Washington's medical school. By 2025, some estimates 
are that Alaska will need nearly twice as many physicians as practiced 
in the State in 2004. This estimate translates to potentially needing 
an estimated 1,347 physicians within the next 10 years.\2\
---------------------------------------------------------------------------
    \2\ Adequate Number of Physicians for Alaska's Needs: Report of the 
Alaska Physician Supply Task Force, April 2006.
---------------------------------------------------------------------------
    VA as well as private health care systems will be affected by this 
shortage. The Alaska VA Healthcare System (VAHCS) serves veterans 
throughout the State of Alaska and is part of Veterans Integrated 
Service Network 20. Primary, specialty, and mental health outpatient 
care is provided by the parent outpatient clinic located in Anchorage; 
at community based outpatient clinics (CBOCs) in Fairbanks, Kenai, and 
Wasilla; and at an Outreach Clinic in Juneau. Inpatient services are 
provided through fee basis arrangements with community hospitals and a 
joint venture (JV) with Department of Defense Joint Base Elmendorf-
Richardson, located adjacent to the parent outpatient clinic in 
Anchorage.\3\
---------------------------------------------------------------------------
    \3\ ``Fee-based care'' is a term that refers to purchasing health 
care outside the VA system. This term has been replaced by non-VA 
medical care or purchased care. When this care is obtained through a 
provider placing a consult, it is called a Non-VA Care Consult.
---------------------------------------------------------------------------
        prior reviews related to access to health care in alaska
    The OIG has reviewed challenges faced by Alaska veterans in 
accessing this health care network in two previous reports. In 2005, 
the OIG published the report Healthcare Inspection--Surgical Service 
Issues, Alaska VA Healthcare System, which examined timely access to VA 
patients' surgical needs.\4\ The OIG found that VA patients' surgical 
needs were not being effectively met by the JV hospital arrangement 
with Joint Base Elmendorf-Richardson, particularly for patients 
awaiting orthopedic surgery. Our report also substantiated lack of 
compliance with Veterans Health Administration (VHA) directives and The 
Joint Commission (JC) standards requiring the Chief of Surgical 
Services to be a physician (this position was being filled by a 
Physician Assistant). The OIG received documentation that the facility 
had implemented recommendations from this 2005 report and closed those 
recommendations in November 2005.
---------------------------------------------------------------------------
    \4\ http://www.va.gov/oig/54/reports/VAOIG-05-02527-205.pdf, 
published September 20, 2005.
---------------------------------------------------------------------------
    Then, in 2010, the OIG conducted a review of patient referrals and 
transfers from the VA system in Anchorage to VA specialty care 
providers outside of Alaska and published the report Healthcare 
Inspection--Review of Patient Referrals to Lower 48 States at the 
Alaska VA Healthcare System, Anchorage, AK.\5\ The vast majority (96 
percent) of patients were able to receive health care directly through 
the Alaska VAHCS or indirectly through Department of Defense JV 
agreements and community-contracted and fee-based services in Alaska. 
Approximately four percent of patients received specialty care outside 
of Alaska, primarily for orthopedic, neurosurgery, neurology, oncology, 
and cardiology specialty care services. The OIG made no 
recommendations.
---------------------------------------------------------------------------
    \5\ http://www.va.gov/oig/54/reports/VAOIG-10-01509-241.pdf, 
published September 9, 2010.
---------------------------------------------------------------------------
    VHA has also reviewed veterans' access to health care in Alaska. In 
response to our oversight reports addressing serious scheduling and 
access to care issues at the Phoenix VA Health Care System, VHA 
conducted a system-wide audit of scheduling and access management 
practices; this audit included the Alaska VAHCS in Anchorage. Of the 
216 sites visited in VHA's Phase One Access Audit, 81 (37 percent) were 
identified as needing further review; the Alaska VAHCS was not one of 
the sites identified as needing further review. VHA reported as of 
May 15, 2014, the Alaska VAHCS reported scheduling 91 percent of 
appointments in 30 days or less. Also according to VHA, as of 
December 5, 2014, the Alaska VAHCS was able to schedule 99 percent of 
appointments in 30 days or less. We did not independently verify the 
results of VHA's work.
                    oig 2014 alaska vahcs inspection
    While the Alaska VAHCS as a whole reported overall good access to 
care, our recent inspection revealed that there were significant access 
to care problems at the Mat-Su clinic in Wasilla, Alaska. The OIG 
conducted the inspection in August 2014 at the request of Senator Lisa 
Murkowski to assess the merit of the following allegations:

     The Mat-Su clinic in Wasilla, Alaska, did not have 
adequate staffing or security.
     The lack of staffing led to poor access to care and poor 
quality of care for Wasilla veterans.
     The Alaska VAHCS had engaged in improper scheduling 
practices and failed to provide follow-up care for veterans after the 
Alaska VAHCS's only urologist left.
Inspection Results
    OIG's inspection results are described below:

    Allegation: The Mat-Su clinic in Wasilla, Alaska, did not have 
adequate staffing or security--The Mat-Su VA clinic opened in 
March 2009. VA successfully recruited a physician to staff the clinic 
within 6 months. VA hired a second physician in April 2011, but the 
second physician left a year later, leaving only one doctor to care for 
1,700 patients. VA policy recommends that a primary care provider 
should not be responsible for more than 1,200 patients. The second 
physician, citing excessive workload, left the Mat-Su clinic in 
May 2014. Between 2012 and 2014, the clinic was open 66 days without a 
licensed independent practitioner onsite. The nurses, medical 
assistants, and other staff were left to care for patients with only 
intermittent back-up from Anchorage providers, locum tenens physicians, 
and contractors.\6\ VA took steps to obtain care for these patients at 
the Southcentral Foundation, an Alaska Native-owned non-profit 
community health organization, but the delays in obtaining that care 
left veterans without consistent care during the transition. In short, 
we substantiated that the Mat-Su clinic in Wasilla did not have 
adequate staffing. VA policy requires facilities to maintain 
contingency plans for providing continuity of care during periods of 
understaffing or limited resources. The Anchorage VAHCS had no such 
plans in place. However, we did determine that security procedures at 
the Mat-Su clinic complied with VA policy.
---------------------------------------------------------------------------
    \6\ Locum tenens is a Latin phrase that means ``to hold the place 
of, to substitute for.'' Locum tenens staffing began in the early 1970s 
with a Federal grant to provide physician staffing services to rural 
health clinics in medically under-served areas of the western United 
States. The program proved so successful that today locum tenens 
companies provide physician staffing services for hospitals, outpatient 
medical centers, government and military facilities, group practices, 
community health centers and correctional facilities. http://
www.locumtenens.com/about/locum-tenens.aspx. Accessed August 19, 2015.

    Allegation: The lack of staffing led to poor access to care and 
poor quality of care for Wasilla veterans--To determine the impact of 
inadequate staffing on patient care, we reviewed the care of all 
patients assigned to the Mat-Su clinic who died between July 24, 2013, 
and July 31, 2014.\7\ We determined that 40 patients assigned to the 
Mat-Su clinic died during this time interval. Of those patients, we 
found that nine received poor access to care. We further determined 
that this poor access to care resulted in poor quality of care for 
seven of those nine patients. All nine patients are described in the 
report. For purposes of our testimony today, I highlight one of those 
cases.
---------------------------------------------------------------------------
    \7\ We selected this date range for review because it began exactly 
1 year after the first provider left, allowing us to assess the impact 
of the clinic's understaffing through the departure of both the first 
and second providers at the clinic.
---------------------------------------------------------------------------
    This veteran, referred to as Patient 8 in the report, was in his 
70s. He had a history of malignant melanoma on his shoulder. He had 
surgery to remove the cancer and had a teledermatology appointment in 
spring of 2013 for follow-up care. The dermatologist recommended that 
he be seen every 6 months for his condition. In fall of 2013, he went 
to the Mat-Su clinic complaining of shoulder pain. The Mat-Su provider 
did not consult the dermatologist for follow-up care, but instead sent 
him to an orthopedic surgeon. The orthopedic surgeon gave him a steroid 
injection.
    A few weeks later, the veteran called the Mat-Su clinic complaining 
of continued shoulder pain. He received instructions on how to take 
anti-inflammatory medications. He returned to the clinic in spring of 
2014, about 6 months later, for routine bloodwork. He still had not 
received a follow-up appointment with a dermatologist.
    One month later, he presented to a non-VA emergency department with 
complaints of ongoing, worsening shoulder pain. The emergency 
department physician, worried about a recurrence of his cancer, ordered 
a chest CT scan.\8\ This scan identified multiple lesions throughout 
the chest. The patient was diagnosed with metastatic melanoma, admitted 
to hospice, and died a few weeks later.
---------------------------------------------------------------------------
    \8\ A computed tomography (CT) scan is an imaging method that uses 
a series of computer-processed x-rays to create pictures of cross-
sections of the body.
---------------------------------------------------------------------------
    If this veteran had received regular follow-up care from a 
dermatologist or his primary care physician, the recurrence of his 
cancer may have been discovered earlier. Early detection increases the 
chances for successful treatment, however, there are many significant 
factors beyond early diagnosis and treatment that impact oncology 
patient outcomes. As a result, we cannot say with certainty whether 
earlier detection alone would have extended his life without question.
    During the course of our review, we identified multiple 
deficiencies in the Alaska VAHCS that hampered the ability of system 
leaders to respond to the ongoing access to care challenges at the Mat-
Su clinic in a timely and effective way. We found gaps in the reporting 
of peer review results to system leadership, and in the ongoing 
professional practice evaluations of medical staff. For example, VA 
policy requires that the practice of all physicians be reviewed every 6 
months to ensure ongoing competency. The results of these reviews must 
be reported to and approved by certain medical center committees. Our 
review determined this was not being done regularly. We further found 
deficiencies in the reporting of information to the Alaska VAHCS's 
leadership, in part because of a culture of distrust between management 
at the Anchorage facility and staff at the Mat-Su clinic. Patient care 
was compromised by a lack of communication, care coordination, and 
follow-up in addition to outright delays in the provision of care.

    Allegation: The Alaska VAHCS had engaged in improper scheduling 
practices and failed to provide follow-up care for veterans after the 
Alaska VAHCS's only urologist left--We also substantiated that the 
Alaska VAHCS had inappropriate scheduling practices, but determined 
these practices had been discontinued in 2009. We further found that 
the Alaska VAHCS did not ensure appropriate follow-up care for one 
patient following the departure of the Alaska VAHCS's only urologist in 
September 2008. In addition, we reviewed consult data for the quarter 
immediately following the urologist's departure. During this timeframe 
(October 1--December 31, 2008), 123 consults were completed. 39 were 
completed in less than 30 days; 50 were completed in 30-60 days; and 34 
took longer than 60 days to be completed.

    In sum, we made nine recommendations for improvement addressing 
access to care, lack of staffing, and management issues in the Alaska 
VAHCS. The Veterans Integrated Service Network and System Directors 
concurred with our recommendations and provided an acceptable action 
plan.
    other oig initiatives regarding alaska or access to health care
    The OIG has several oversight projects planned or underway that 
focus on the Alaska VAHCS and/or issues related to veterans' access to 
health care. Just this month, the Office of Healthcare Inspections 
(OHI) conducted a Combined Assessment Program (CAP) review of the 
Alaska VAHCS as well as a CBOC review in Fairbanks. CAP and CBOC 
reviews evaluate selected health care facility operations and patient 
care activities at VA facilities on a cyclical basis. We are in the 
process of analyzing the data, and we expect to issue our reports in 
the next 3 months. In addition, we are returning to assess access 
issues at other locations in the Alaska VAHCS next month.
    The Office of Healthcare Inspections has also reviewed staffing 
shortages nationwide as required by the Veterans Access, Choice, and 
Accountability Act of 2014. The first report, published in January of 
this year, ranked the physician occupation as the occupation with the 
largest staffing shortage in VHA.\9\ The second report will be 
published by September 30, 2015, ranked the physician occupation as the 
occupation of most critical need in VHA.
---------------------------------------------------------------------------
    \9\ OIG Determination of Veterans Health Administration's 
Occupational Staffing Shortages, published January 30, 2015, http://
www.va.gov/oig/pubs/VAOIG-15-00430-103.pdf.
---------------------------------------------------------------------------
    Other components of the OIG are commencing work on the Veterans 
Choice Program. In August 2015, the Office of Audits and Evaluations 
began a review of VHA's implementation of this program. The objective 
of the review is to determine whether VHA staff have sufficient 
knowledge of the Veterans Choice Program to inform veterans of their 
non-VA care options. We plan on publishing a report of our findings and 
recommendations in early 2016. This is in addition to the requirement 
in the Veterans Access, Choice, and Accountability Act of 2014 for the 
OIG to provide a report on the timeliness and accuracy of payments once 
75 percent of the funds have been expended.
                               conclusion
    Meeting the health care needs of Alaska veterans must remain one of 
VA's highest health care priorities. Although factors related to 
Alaska's location and geography pose challenges to providing health 
care services, the Alaska VAHCS must work to address the issues we have 
identified to ensure all of Alaska's veterans have access to timely and 
high quality health care. We look forward to continuing our oversight 
work of these important issues. Mr. Chairman, this concludes my 
statement. I would be pleased to answer any questions you or other 
Members of the Committee may have, and to working with you in the 
future on these challenging issues.

    The Chairman. Thank you, Dr. Buck. I think we can all learn 
a lot from your IG report, the fact that we literally had a 
veteran die, at least one, in Alaska, because of our inability 
to manage what we are supposed to be doing. It is something 
that is obviously unacceptable and something that we have to 
focus on. This clinic in the Mat-Su, we need all the brainpower 
in the VA, and if you need authorities or ideas or you need 
help from Congress, I am all ears. We have to get physicians 
back to one of the most important parts of our entire State, 
where there are thousands of patriotic veterans who are not 
getting the care they need, even though there is a facility 
there and willing partners, as we talked about.
    I appreciate your testimony. I am just sickened by the 
outcome. We have to commit to make sure that that never happens 
again in our State.
    Mr. McIntyre.

  STATEMENT OF DAVID MCINTYRE, PRESIDENT AND CHIEF EXECUTIVE 
                  OFFICER, TRIWEST HEALTHCARE

    Mr. McIntyre. Good evening, Mr. Chairman. I want to thank 
you and the Senate Veterans' Affairs Committee for the 
invitation to appear before you as part of this important 
hearing on how we achieve the right paradigm of delivering care 
closer to home for veterans here in the great State of Alaska. 
I am honored to be part of the panel, and I ask that my entire 
written testimony be accepted into the record.
    The Chairman. Without objection.
    Mr. McIntyre. Thank you, sir.
    No one is more frustrated and tortured than me at what I 
heard. We have spent millions as a company trying to get this 
right. The bottom line is that we built out a network in this 
State, now 1,200 providers and 28 facilities that we ask to 
lean forward. We got a law that was not ready for certain 
pieces of implementation, from a funding and requirements 
perspective. You all have been able to address those issues and 
fix those recently in the stuff that was attached to the 
highway bill, and that is most appreciated.
    As was articulated previously, when we started up the 
Choice Act, the funds quickly got to a place where the 
direction was given that the only money that can be spent comes 
out of Choice. The DOD facilities were not ready, the 
infrastructure was not in place to make that move, and the same 
thing was true on the tribal care perspective.
    The challenges in terms of the delivery of service 
absolutely no question have been difficult. We started in a 
place where we had no idea what demand was going to look like. 
We are now at 50,000 appointment requests a month. Eight weeks 
ago, we were at 35,000.
    The Chairman. For what region?
    Mr. McIntyre. For 28 States, the Pacific, including Alaska.
    We are now at 50,000 appointment requests a month. We have 
a network outside of Alaska, including Alaska, of 125,000 
providers. A year ago, we were at 40,000. We were at 400 staff 
in March. We are at 1,600 staff as of last Friday. We are 
headed to 2,500 staff by the end of November.
    None of us understood what demand was going to look like. 
Being able to map this network to make sure that it works is 
critical. Then being able to match supply of staff to handle 
demand is critical.
    I would say, from my personal perspective, as someone who 
proudly has had a very long association with this great State--
my dad was the first ophthalmologist to ever spend time in 
Alaska. I grew up in Seattle. I served on the Indian Affairs 
Committee as a staffer in the Senate. I am responsible for the 
638 authority as a staffer that allowed the native corporations 
to do the amazing work that they have done to run their own 
delivery system rather than the Indian Health Service. No one 
wants to dislodge that. It is not the right answer.
    What I have heard pains me. It pains everybody in this 
audience. The fact of the matter is that we are getting 
prepared to take all the ZIP Codes for Alaska and point them at 
Puyallup in the next week, so that nothing will be touched 
anywhere outside of the Northwest, which is the referral 
pattern, if the care cannot be delivered in Alaska.
    The challenge is, when you have the kind of growth that we 
have experienced, you have to be able to build it out. We have 
done that in weeks, not in months, in weeks. The challenge is 
getting people trained, getting them properly and effectively 
where they need to be at the end of the day in order to make 
this work.
    When Choice was enacted, the Choice law carried with it at 
the time a limitation on what reimbursement rates would look 
like capped at 100 percent of Medicare. That does not work in 
this State. That has now been adjusted. That has now been taken 
care of. We now have great providers in the State that are 
saying we will lean forward.
    At the end of the day, I support the VA. My job, my 
company's job that I am privileged to run--I do not own. I 
built this 20 years ago. We proudly serve Alaskans at the side 
of the Defense Department. Our job is to make sure that when 
the VA cannot do the work directly that we are there for them. 
We have work to do. We have work to do to get this right. We 
appreciate the partnership with Congress. We appreciate the 
changes that have been made thus far. We still have work to be 
done between us, the VA, and Congress to get the Choice Act 
where all the component parts are going to work effectively.
    I am responsible and will be accountable for the service 
delivery of our organization. As I have heard tonight, it is 
not where it needs to be.
    Then I run into others who say they had an amazing 
experience, so it is a blend. You do not want the blend. You 
want everything to be to the right. You want it to work 
properly.
    I listened with interest to Dr. Shulkin, a person who 
stepped up into this job and said I am here because I want to 
be part of the solution, I want to help make this work. What I 
will tell you is we will follow what the VA and what Congress 
decide the State needs to look like in Alaska. We are going to 
stand and wait until that decision is made because we spent a 
lot of money trying to get this right--it is our own money; it 
is not the government's money--trying to make sure that we can 
get the infrastructure build out to be able to respond.
    We stand ready to do our part. We will be accountable for 
the lack of service where it has existed, and we look forward 
to the continued work with the VA and Congress to make sure 
that this program, both in Alaska in whatever form it is going 
to take and in the lower 48 and the Pacific, rises to the 
occasion.
    Mr. Chairman, thank you for allowing me to testify.
    [The prepared statement of Mr. McIntyre follows:]
 Prepared Statement of Mr. David J. McIntyre, Jr., President and CEO, 
                      TriWest Healthcare Alliance
    Good afternoon Mr. Chairman, First, I want to thank the Committee 
for the invitation to appear before you today in Eagle River, Alaska. 
And I am particularly pleased to be here with VA's Under Secretary for 
Health, Dr. Shulken. I hope it will become obvious quickly how closely 
together our two organizations are working every day to improve access 
to care for Veterans here in Alaska and across the vast territory in 
which we are privileged to serve at VA's side.
    I know you've called this hearing to receive answers related to 
several challenges here in Alaska for Veterans who are attempting to 
access care from community providers, including through the Veterans 
Choice Program. I hope my testimony can provide some answers to your 
questions.
    I have had a long and proud personal association with the health 
care community of this amazing state going all the way back to when my 
father, an ophthalmologist, used to ride the circuit every other month 
for many years of my childhood delivering care to those who were 
underserved across Southeast Alaska. Decades later, TriWest Healthcare 
Alliance, the company I helped found, and have been privileged to lead 
for nearly 20 years, delivered the TRICARE program here in Alaska. And 
now I am proud to partner with VA in their efforts to increase access 
to care from local providers in this great state * * * the Last 
Frontier!
    Mr. Chairman, at the outset, I think it is fair to say that the 
implementation of the Choice program in Alaska has not gone as well as 
anyone would have liked. And, I want to personally commit to you; the 
Veterans of this State; the medical community; and of course those of 
whom we work at the side of in VA, that we will work tirelessly to 
correct whatever deficiencies we might have. In fact, as I will discuss 
a little later in my testimony, we have already begun that work. More 
importantly, we are committed not just to correcting deficiencies, but 
in fact, improving the experience of the Veterans in need of care, as 
well as the providers in the community who deliver those services in 
Alaska if that be the desire.
    Mr. Chairman, before describing some of our challenges, our plans 
for fixing them, and discussing some programmatic challenges that I 
hope your committee will consider, I'd like to take a moment and go 
back to the time before the Choice program to discuss the progress we 
were making in Alaska in administering the Patient Centered Community 
Care (PC3), program.
    As I mentioned earlier, TriWest previously worked in Alaska 
managing the TRICARE program. We were well-aware that building a 
network to replace what VA had been doing under the traditional fee 
program would take time, collaboration with VA, and would require us to 
patiently engage the provider community to ensure everyone understood 
our responsibilities and our goals. After all, many of these providers 
had been serving Veterans in some fashion for many years and it was 
important to all of us that they continued to do so. This was 
especially true in those locations off the road system.
    Our approach, which we developed in collaboration with the Alaska 
VA Medical Center Director, with the support of your Senate colleague, 
Lisa Murkowski, was to start in Anchorage and Fairbanks, where, as you 
know, a substantial portion of specialty care is provided. Then, once 
we established good processes and relationships for those services and 
we were accepted as a reliable partner, we could turn our attention to 
the more rural providers in the bush areas of Alaska to fully 
transition the community care work to the PC3 program.
    Additionally, we were highly sensitive to the relationships VA had 
already established with the Tribal Health System * * * facilities and 
providers that are a part of the Alaska Native Health Consortium. We 
understood there were both Alaskan Native and non-Alaskan Native 
Veterans able to access those facilities under Memorandums of 
Agreements established between VA and 26 of the 27 tribes in Alaska. We 
briefly discussed whether non-Alaskan Native Veterans could be 
transitioned to the PC3 program. But, just as quickly, we discovered 
the payment structure looked nothing like the contract we have with VA 
and all parties were satisfied with the current arrangement. As such, 
we simply left it alone.
    While the volume of work coming through the PC3 program initially 
was not large, that was a good thing. It allowed us the time to focus 
on establishing trust and explaining the new program. Frankly, I 
believe our plan was working reasonably well. We had regular 
consultation with VA in Alaska where we discussed the needs for care in 
the community, our network, where it was in need of growth, and whether 
that growth was possible. Like all new programs, we had hiccups and 
gaps, but we were working together to iron them out.
    An example of this close coordination was the need for Veteran 
access to primary care across the state. We worked closely with the 
Alaska Primary Care Association (APCA) to determine their ability to 
support the primary care needs of the Alaska VA. This coordination 
resulted in a three phased agreement between TriWest and APCA. The 
first phase, initiated in the early summer months, was to survey the 14 
non-tribal APCA federally qualified health clinics (FQHCs) to determine 
their interest in signing Choice Provider Agreements. The second phase 
involved signing those interested FQHCs to negotiated Choice Provider 
Agreements with a third phase following to convert those same 
facilities to PC3 network status. I am pleased to report today we have 
recently been contacted by APCA and all 14 of the original FQHCs and a 
newly awarded FQHC, will be signing Choice Agreements. At present, 6 of 
the 15 agreements have been signed and returned to TriWest; we believe 
the remainder of the agreements will be completed before the end of 
August. The Alaska VA has favorably commented on the new access to care 
for non-Native Veterans in rural locations of the state.
    I think it is also important to note that the rate structure under 
the PC3 program generally allowed TriWest to pay competitive, market 
rates to providers in the community. Typically, we offered providers an 
amount in excess of 100% of the Medicare schedule in Alaska, but we 
also had the flexibility and responsibility to ensure we did not pay 
more than was needed to acquire the services. After all, we are 
spending taxpayer dollars. We fully launched the PC3 program in Alaska 
in April 2014.
    Shortly thereafter, a few thousand miles away, as we all know, 
issues concerning wait times came to the forefront at the Phoenix VA 
Medical Center. And, a few months later, in August 2014, Congress 
passed the Veterans Access, Choice, and Accountability Act (VACAA), 
which created the Veterans Choice Program. Only 90 days later, VA 
modified our PC3 contract and added the responsibility to administer 
the Choice program to it. Unfortunately, I think our collective 
challenges began at this time * * * given a 30 day window to design and 
implement a massive and complicated new program.
    Mr. Chairman, I think it is important to discuss some of the 
programmatic and statutory challenges the new Choice program faced when 
we first got the modification. But, I do not want to sit before this 
Committee and simply suggest that the challenges are someone else's 
fault. TriWest bears responsibility for some of the challenges in 
execution of the new program and I'd like to discuss our shortcomings 
right up front.
    First, the call center experience for Veterans who reached one of 
the 800 staff that had to be hired in 10 days to stand up the program 
in the timeframe mandated in the law, to seek assistance accessing 
their care has been inconsistent at best, and flat out unacceptable at 
worst. It will never be acceptable to me or my company to provide a 
customer experience that has Veterans waiting on hold for extended 
periods of time only to be told--incorrectly--that they are not 
eligible for care under the program.
    Additionally, I know it goes without saying in this room, but 
Alaska has an incredibly unique and complex geography. But, we knew 
that. We had served in this state before and it was our job to 
accommodate for that. You should have expected us to know that while it 
may be true that the closest specialist available to treat a Veteran in 
Barrow may be in Fairbanks, that doesn't mean that Veteran can drive 
there tomorrow for the appointment. You should know that we have taken 
steps to correct this deficiency and ensure that our staff who interact 
with Alaskan Veterans understand Alaska.
    I have stated in the past * * * on the record before this Committee 
in Washington DC * * * that we have experienced our fair share of 
training challenges. Certainly some of those challenges stem from the 
incredibly quick implementation timelines for the Choice program, and 
others from the sheer number of changes that have occurred to it, in 
Alaska alone, since we went live less than 8 months ago. But, some of 
the training challenges rest solely with us.
    To fix the problems with the customer experience I have just 
outlined, we have taken a number of steps over the past several months. 
First, I instructed our team to designate our call center in Puyallup, 
Washington, just outside of Tacoma, as the primary call center that 
will serve Alaska's Veterans. Anytime a Veteran enters an Alaska zip 
code when calling the Choice Line, it should first be routed to 
Puyallup. It should have been obvious to me from the start that we 
needed a special cell of employees to handle the care needs of Alaska 
Veterans. We now have that.
    We have also updated our training and oversight efforts to ensure 
the right employees stay on the phones working with our customers while 
those who need additional training can get it. If it is simply the case 
that some staff can better serve the company and our Veterans in a non-
customer-facing position, then that is where they serve. It took us 
some time to effectively project the demand and then select the right 
staff in sufficient supply to meet that demand and allow others to move 
to non-customer-facing work.
    Finally, some of the hold times for Veterans in Alaska and around 
the country are higher than we would like given the fact that supply of 
staff has been chasing the incredible growth we have seen in referrals 
to the Choice program since early June. Just two months ago, TriWest 
was receiving somewhere between 400-500 Choice authorizations per day 
or a total of about 10,000 per month. Today, we receive upwards of 
2,500 authorizations per day, or the equivalent of 50,000 per month.
    However, in an effort to keep up with the extensive growth, we have 
had a massive hiring effort underway * * * and are adding new staff 
every week, and will ultimately have somewhere around 2,500 staff by 
November. In fact, we have already expanded our contact centers in 
Puyallup and Phoenix. We have stood one up in Honolulu to serve the 
Pacific and Tempe to further serve the greater Phoenix area. Employees 
are coming on board with the centers soon to open in San Diego and 
Kansas City. We are executing leases for centers in Sacramento and New 
Orleans. We are searching for space in Texas. And, I just came from 
Nashville, where we announced on Friday that we are hiring several 
hundred staff as we prepare to open that site in October. This scale 
will be fully operational by the end of the year.
    My expectation is that in the next month or so, once more of these 
new staff are online, we will be able to fully handle demand and ensure 
that our special Alaska cell in Washington State is available on a more 
routine basis to take the Alaska cases and ensure we deliver that 
consistent, high-quality experience Veterans have earned.
    Of course, I have been pretty upfront about the fact that some of 
the challenges in Alaska have been outside of our control.
    First and foremost of these issues was the rate structure initially 
required by the VACAA legislation. As you likely know, when that bill 
first passed, it required that all care be reimbursed at rates up to, 
but not to exceed 100% of Medicare. There was some flexibility given 
for highly rural areas. But, even if the highly rural allowance could 
have solved for some areas of Alaska (which it would not have), the 
bulk of the care is provided in Anchorage and Fairbanks, not highly 
rural areas. As I mentioned previously in my testimony, we knew from 
our TRICARE and PC3 program experience, that obtaining most 
professional services in Alaska at 100% of Medicare is simply not 
possible. Moreover, we refused to modify our contract to suggest we 
would even try.
    You see, our fear was that if we started attempting to push care 
through the Choice program into the community at rates far below the 
market requirement, we could forever damage ours and VA's ability to 
turn again to the provider community with a Veteran in need of care. In 
short, we believed that would have been explosive.
    To VA's credit, their officials also understood the dilemma and 
worked with the Hill to get some relief for the rate structure in 
Alaska. That change, however, took time and it did not pass Congress 
until sometime in December 2014 as part of H.R. 83, the Omnibus 
Appropriations Act.
    Meanwhile, Veterans in Alaska were receiving their Choice Cards in 
the mail as required by our contract and expected by Congress. Those 
cards came with a letter that told Alaska's Veterans that they had 
eligibility for care that exempted them from having to go to the VA 
medical center before receiving care in the community. As you know, 
that so called 40-mile eligibility is based on the fact that the state 
does not have a full service VA medical facility. Only Hawaii, Alaska 
and Guam in our geographic area of operations have Veterans with such 
eligibility. This simple fact in and of itself created some training 
challenges for both VA and my team at TriWest.
    Further, that unique eligibility was now running headlong into a 
system where we could not appoint Veterans in the community due to the 
rate challenges I noted above. And, of course, this was all occurring 
before I made the decision to create the special cell of staff to serve 
Alaska's Veterans I noted above. The net result was a poor customer and 
provider experience in the State. Unfortunately, two additional issues 
would be overlaid on these initial startup challenges.
    The new challenge after startup came in the form of the 
modification to our contract to update the rate structure so that we 
could begin to engage providers at a rate more attuned to the market. 
The problem with the new modification was that it would have required 
us to pay a substantial portion of providers at rates far in excess of 
what their market rate in Alaska would demand. We simply had no 
flexibility to do otherwise.
    Unfortunately, just like an artificially low rate could have caused 
damage in the community, so too an unreasonable high rate, 
unintentionally required by the VA contract, could have substantially 
distorted potentially all health care rates in Alaska, making VA the 
leading payor for many services. I am sorry to say that it took us 
until the end of February to work through those challenge and 
ultimately settle on the fact that we would pay providers who engaged 
with us only for the Choice program (as opposed to a full network 
arrangement under PC3) at the same rates as VA paid under its Alaska VA 
Fee Schedule--a rate unique to Alaska.
    Having gotten past that point, we believed we had settled back into 
a structure through which we could work with providers in the 
community.
    In June of this year, we heard the news that VA in Alaska was 
telling providers that it could no longer spend money through its 
traditional Fee Basis budget and that all care was to come through the 
Choice program. We had heard the testimony from the Deputy Secretary, 
but did not initially compute what that would mean in Alaska.
    I mentioned we were confident we had finally settled on a workable 
structure for most care. However, I also mentioned at the outset of my 
testimony, we were determined not to interfere in the relationships 
between the Tribal Health System and the Alaska VA Healthcare System. 
We came to understand those services were all reimbursed with Fee Basis 
or what is also called non-VA care funding. As you know, the idea that 
we would now be a party to those arrangements did not sit well with the 
Native Corporations, VA, or frankly with us.
    As you know Mr. Chairman, the Tribal Health System challenge has 
too been resolved through a lot of conversation, hard work, and 
certainly some criticism. However, the accumulation of all the 
challenges I have mentioned has no doubt left a lasting, and 
unfavorable impression in the community with respect to the Choice 
program in Alaska. Yet, I think most of people here today believe that 
more options for Veterans and more coordination with the private sector 
is truly the long term answer to care for Veterans in Alaska. So that 
question is how do we get better and achieve that outcome.
    For our part, I mentioned some of things we are doing to improve 
the customer experience in my testimony earlier. But I do want to 
mention another initiative that we are collaboratively exploring with 
VA and we are willing to undertake it if everyone agrees it is the 
right next step.
    We know from our work during the TRICARE program that having staff 
on the ground in Alaska can go a long way toward making the use of the 
program a more seamless experience. Those TriWest staff got to know the 
government staff, the beneficiaries, and also the providers in the 
community. All of that helped speed the process of getting care 
provided in a timely manner downtown. We have that opportunity again.
    A few months ago, we had preliminary discussions with the VA in 
Alaska to determine whether housing some staff in their facility in 
Anchorage would be welcome. Their preliminary feedback is that it would 
be welcome and would help with the processes necessary to providing 
care in the community. We have developed a template for placing those 
staff here. But, we want to make sure we are back on sound footing here 
in the state before we hire and place that team.
    In the short run, TriWest staff working every day alongside their 
VA colleagues will identify process challenges quickly and implement 
solutions even faster. That structure will provide care authorized in a 
more timely manner and ensure better daily coordination at a personal 
level instead of faxes, phones, internet portals and emails.
    In the long run, it is my hope that we can reach a point where we 
have a strong cadre of trusted providers in the community and, just as 
with the TRICARE program, we can begin to rely on those providers to 
make health care recommendations and trust them to carry out that care 
without intervening, artificial processes adding unnecessary 
administrative burden to providers.
    Today, as you know, most recommendations for standard care 
practices require additional review and authorization either by TriWest 
or VA. Those processes are frustrating to providers and to Veterans, 
delay care, and ultimately impact the cost and quality of the program. 
It is our hope that one day we might get to a position where providers 
are able to efficiently provide care to Veterans in an accepted 
standard of practice. Alaska may prove an ideal place to prototype how 
that system might work across the VA enterprise.
    Finally, Mr. Chairman, I want to go back and emphasize that one of 
the most important things that can help all of us get back on sound 
footing here in Alaska, once and for all, is decide on a rate structure 
we can use that will pay providers what their market rate demands, 
while still ensuring we can continue to be good stewards of the 
taxpayers' dollars. We know that is a complicated endeavor. But, 
without it, instability will continue.
    Mr. Chairman, I hope my testimony here has provided some useful 
information as well as context for some of the challenges the Veterans 
of this state have experienced. But, I also hope it has convinced you 
that the company I am proud to lead considers it an honor and privilege 
to work every day to provide access to care for those who have served 
this Nation in uniform. It is an awesome responsibility and our owners, 
and all of my colleagues in leadership take it very seriously.

    Thank you again Mr. Chairman for this opportunity. I look forward 
to answering any questions you might have.

    The Chairman. Thank you, Mr. McIntyre.
    Listen, a lot of times in a hearing like this, particularly 
given the issues, particularly given the outrage--Dr. Shulkin, 
you saw it. With all due respect, Mr. McIntyre, we spent the 
last 2 days talking to hundreds of veterans, and I do not think 
I heard anyone who said they had an amazing experience under 
TriWest. Certainly, the phone ringing off the hook in my office 
is not indicative of people having an amazing experience.
    On a hearing like this, and you have seen them, you have 
all been in front of panels like this, this is sometimes the 
part where the questioner gets a little upset because there is 
a lot to be upset about here, whether it is dead veterans in 
Alaska because of wait times, whether it is literally thousands 
of Alaska's finest not getting the service they earned.
    I am kind of wavering between that element of frustration 
and anger, and focusing on the questions on how we fix this. 
That is what this is all about.
    Let me start by asking a couple of questions.
    The issue of local control came up in literally every 
single one of our meetings and engagements. Again, the VA was 
not perfect here, but I think given the local control aspects, 
it was viewed by most as working relatively well.
    When I read the Choice Act, it does not mandate a third-
party administrator to come in and add a brand-new layer of 
bureaucracy to the whole system, particularly for our State a 
bureaucracy that seems very distant, very unaccountable, very 
clueless with regard to Alaska, particularly when it has call 
centers based in Texas and Louisiana and in places like that.
    Why did we put appointments and authorizations under the 
new layer of bureaucracy by TriWest when the act does not even 
mandate that? Why did we do that? It is one thing if you read 
the law and it says you have to go to that. OK, well then, 
Congress, you have to go fix that. But there is nothing in the 
law that mandates this new layer of bureaucracy, taking the 
local control away, taking the Integrated Care workers who are 
doing such a good job, putting it in TriWest. Then you are 
seeing not only a new layer of bureaucracy but this huge issue 
of the lack of communication between anyone in the VA and 
TriWest.
    It is the theme that we are hearing over and over again. 
Why did we do that? I am baffled.
    Dr. Shulkin. Senator, I think you have gotten to the crux 
of the matter. I was not here, so I do not know why it happened 
that way, but it does not matter because what we heard over the 
last couple days is that we cannot let this continue. It is not 
working.
    What I think, rather than responding defensively or getting 
angry about this, because I can get angry about it too, I want 
to focus on the solution. What I am hearing Mr. McIntyre say is 
that he has personally committed and his company has committed 
to fixing this.
    The way that we would fix this is by us redesigning this so 
that it goes back into the hands of the local VA providers here 
in Alaska who have worked with our community partners for years 
and years, and have worked with our veterans overwhelmingly in 
a positive way. We heard that consistently.
    The Chairman. Correct. I would agree with that.
    Dr. Shulkin. Therefore, this really needs to be the VA and 
TriWest sitting down and redesigning the system. I believe I am 
hearing that commitment from Mr. McIntyre to make this work for 
our veterans.
    The Chairman. Mr. McIntyre, can you address Dr. Shulkin's 
comment, but also my question on the reason it happened in the 
first place?
    Mr. McIntyre. I would absolutely respond to both.
    As I indicated, I certainly am willing to follow the lead 
of Dr. Shulkin. I appreciate him stepping up.
    It seems to me that the future of Alaska is really in the 
hands of the VA and Congress. You all need to decide and let us 
know what we should do.
    What got implemented was also in the hands of Congress and 
at the time the VA. We all were given 30 days, practically, to 
implement a new law, not design a Web site and stand it up, 
implement an entirely brand-new program to respond to an access 
to care challenge that was articulated by Congress, and covered 
by the media and then responded to by Congress.
    The law was passed in August, and everybody said November 5 
is the deadline and you will not miss the deadline. That is 
what the VA was told. That is what we were told. That means, 
practically, once people were able to sort out what the law 
meant, there were about 30 days to go from a blank sheet of 
paper to full execution.
    You have a lot of background. You know what the 
implications of that are. That is a very, very, very hard task. 
A lot of decisions had to be made by people who were trying to 
grapple with how we do that.
    I think if people had been able to have a year to work 
through that, the outcome might have been very different in a 
lot of different ways. And none of us would be struggling with 
some of the pain that we had to hear about today. It is 
painful.
    The Chairman. You were in Fairbanks. By the way, I 
appreciated you attending that session because, in addition to 
the panel you heard today, it was a litany. Dozens of people 
were upset and in pain.
    Mr. McIntyre. Yes, sir.
    The Chairman. TriWest was obviously dragged through the mud 
during a lot of that. That is why I appreciated you attending 
that and listening. I think it took a lot of guts. I appreciate 
you being willing to do that.
    It is also good for you to guys to see--because it is one 
thing to read about it in a memo. It is quite another thing to 
see the veteran who is literally at the end of his rope because 
he waits on the phone for 4 hours and gets cutoff, never gets a 
call back. It takes him 6 weeks--6 weeks--to schedule an 
appointment.
    Mr. McIntyre. I spend all of my time on those issues. I was 
there in Fairbanks because I wanted to be there to listen.
    The Chairman. I appreciate that.
    Mr. McIntyre. I have been home 1 day in 30, and I will be 
flying tonight to go to Oregon for meetings all day tomorrow.
    Part of the reason for that is we all have work to do. We 
have work to do to try and refine the things that need to be 
refined.
    The Chairman. Let me ask a question on the issue of 
refining. I am not sure I like that term. I mean, I do not know 
if we need to redraw this completely. Refining means tweak on 
the edges. I am not sure the system is even worth refining.
    This is a question I have for the panelists. Do you agree 
that the aspects of Alaska--our size, our very large veteran 
population, our very rural communities, the fact that we only 
have five VA centers throughout the entire State--do you 
believe that we have unique challenges that are more unique 
probably than any other State in the United States?
    Mr. McIntyre. There is no question. There is no question.
    The Chairman. Do you agree with that, Dr. Shulkin?
    Dr. Shulkin. Yes, I do.
    The Chairman. I was not there when the Choice Act was 
passed or implemented, or timelines, but there is no doubt that 
it is a one-size-fits-all piece of legislation.
    Knowing what you know about Alaska, do we need to refine 
what is happening right now, because it is not working, or do 
we need to go back to the drawing board and look at what worked 
and redesign it from the ground up?
    Dr. Shulkin. Let me take that first.
    I believe that we need to do several things that are unique 
for Alaska. One is we have to honor these agreements between 
DOD and the tribal health programs. There is no question about 
that. No one should have any doubt that we plan to do that.
    Second, we need the flexibility to put the funds from Care 
in the Community, the Choice funds and the traditional Care in 
the Community together.
    I understand the first panel's solutions, which is just get 
rid of Choice. The reason why I do not believe that is a good 
idea for Alaska is because we ran out of Care in the Community 
money in Alaska in June. That is when the pain started 
happening for veterans.
    We need more money. Choice is the source of more money for 
Alaska. We need the flexibility to use Choice funds to support 
these relationships that exist today and other providers in the 
community, the specialists and other providers.
    In some ways, it is a refinement, but it is a unique 
refinement for Alaska. Alaska is different, and we need to plan 
this differently because there are places in the country where 
Choice is working well, just not in Alaska and a few other 
places.
    The Chairman. You both would agree that it is definitely 
not working well here?
    Dr. Shulkin. Absolutely. Not working well.
    Mr. McIntyre. No question. I guess I would say that on my 
end, what will be happening is we are moving all the ZIP Codes 
for all the veterans in Alaska and pointing them at the contact 
center in Puyallup.
    The Chairman. What does that mean?
    Mr. McIntyre. That means that no one will ever get touched 
by anyone in Houston, anyone in Louisiana, anyone in New 
Orleans, anyone in Kansas City, anyone in Nashville, anyone in 
San Diego, anyone in Northern California, anyone in Phoenix.
    The Chairman. Why wouldn't you have call centers here?
    Mr. McIntyre. We are going to place a cell of staff here at 
the side of the VA staff that was designed several weeks ago 
between our staff and the VA staff to support what you are 
talking about. Then the apparatus that sits behind them will be 
a contact center.
    The reason for that is as follows. We have to be able to 
flex, and we have to be able to flex based on the amount of 
work that comes in by location.
    The second thing is that people talked about the fact that 
PC3 was working. Where were we serving those people? They were 
being served out of Puyallup, Washington, out of the cell of 
people that are responsible for making that piece work. We are 
going to draw from that.
    The challenge we face, Senator--and I am not making 
excuses, believe me, I am not making excuses. The challenge we 
face is when 7 days before November 5 arrives, and you have to 
have 800 people accessible to do a service, you probably have 
to turn to a third party that can stand up 800 people in a cell 
nearly overnight. That is the decision that we made. We did not 
have a choice, given the timelines.
    Our plan was to always figure out what scale was going to 
look like and then be able to move it so that it was VISN-
centric. VISN 20 includes Alaska. VISN 20 is based out of the 
Puget Sound, out of Vancouver, Washington. It serves Oregon, 
Washington, Alaska.
    The Chairman. Given the complexities here, given the unique 
challenges here, I think you should look hard at people on the 
deck in this State.
    Mr. McIntyre. That is what we are going to do.
    The Chairman. And call centers.
    Let me address kind of a related point. It has come up in 
the hearing today, even Mr. Bowen, for goodness' sakes. 
Literally, the guy knows more about the VA, helping vets, 
probably than any Alaskan.
    There is this idea, there is this problem that comes up, 
and it came up in a lot of our listening sessions, on the 
complexity. Secretary McDonald talked about, and I read it, a 
quote from him, 900 1-800 numbers, 14 different Web sites, the 
single point of contact for a veteran who might be suffering, 
all these Web sites have different passwords for access. The 
complexity of the ability to plug into the system seems 
enormous, and it seems to be ever-changing.
    I think what happened with TriWest involvement in the 
Choice Act is that it just added another level of complexity. 
Literally, some of our veterans just start to give up. They 
throw their hands up, and they give up.
    I know the Secretary is focused on this, but how can we get 
to this level of addressing the complexity and this broader 
issue of continuity of care, which, Dr. Shulkin, you saw came 
up in a lot of our listening sessions? That, again, points back 
to being local control, local control, local control. If we are 
being run by people in Texas or even Puget Sound or D.C., it is 
not good for my State.
    Dr. Shulkin. There is no question, Senator, that the size 
and complexity of the VA health system has created a fragmented 
system. The Secretary has identified as his number 1 
initiative, something called My VA. My VA is a redesign based 
upon the veteran experience to simplify those 900 call centers 
to five regions in the country and ultimately to one call 
center. That will happen.
    Fortunately for Alaska, the solution is simpler because as 
we heard over the past 2 days. What we heard from panel one was 
that they liked their old system. It was working for them. They 
liked their contact with the local VA providers.
    What we want to do is to figure out a way to go back to 
that, where they work with a system that was working. That is 
their handoff. TriWest is helping get this done but in some 
ways in the background and letting the simple system that was 
working in Alaska continue to work.
    The Chairman. Let me ask another question. It is a bit of a 
sidebar issue but just because I think every American, every 
Alaskan, has had this experience with a credit agency riding 
them and threatening them and putting a black mark on their 
credit score and then they spend half their life trying to get 
rid of it. The idea that some of our veterans are getting 
tagged with $30,000, $40,000, $50,000 hospital bills and have 
credit agencies riding them to me is unbelievable.
    I know this was a new one to you, Dr. Shulkin and Mr. 
McIntyre. What can we do? Maybe you do not have an answer to 
this right now, but I would really like it if you could get 
back to me on this, if we need a law, if we need something.
    The idea that some of our veterans are getting tagged with 
this financial responsibility that would crush most people 
anyway, and then have the stress of letters from credit 
agencies threatening to take them to court, it blows my mind.
    Dr. Shulkin. I think both of us, that is one of the things 
we learned by listening over these last couple days. It is 
unacceptable, if the VA authorizes payment for services, to put 
the veteran in the middle. That has to stop. I would ask, since 
I just learned about this yesterday with you, to take this back 
and get back to you with an answer. We cannot allow that to 
continue.
    Commander Watts left his bills with us. We are going to 
track that down. This is just not right to do veterans.
    The Chairman. Mr. McIntyre, do you have any thoughts on 
that one?
    Mr. McIntyre. I totally agree. Under TRICARE, we were the 
fastest and most accurate payer. Right now, we are about 5 
percent off of 30 days, in terms of paying claims. Yet, the 
providers have to understand the rules and everybody in the 
system has to understand the rules, so that you have proper 
alignment in how people get referred and they understand how 
that is all going to work.
    On our end, we have a team of people in our company. They 
do not sit here but there will be people, depending on where 
Dr. Shulkin and Alaska team wants to go on the VA side, we will 
have people in Alaska who will be conduits for any of those 
issues that are problems.
    We do have people who are there for the specific purpose of 
intervening to try to determine where the problem occurred and 
how it gets straightened out. People have to get paid for the 
care they render, and providers should not be pursuing veterans 
when otherwise the care has been paid for.
    The Chairman. No, they should not.
    Mr. McIntyre. Correct.
    The Chairman. Let me go back. I just want a commitment, as 
we look at redesigning this, not tweaking it, but redesigning 
it, if you can take a look at--you are a private-sector 
business, and I respect that--but take a look at the potential 
for call centers here.
    We are unique. Alaskans need people on the line that 
actually understand our uniqueness and our challenges. I would 
ask that you take a look at that, because of the sense of 
frustration that we have felt, that I have seen for weeks now 
of our veterans having to deal with people who are not from 
here and who don't call back.
    Let me ask another question that relates to that. Is there 
work that has been going on to integrate the systems? I am 
talking about the computer systems and the appointment and 
authorization systems between TriWest and the VA. Because once 
again, it looks like a theme here: how many times have we heard 
in the last 2 days that the right hand and left hand are not 
talking to each other? Probably five or six times.
    Mr. McIntyre. To take your second question first, it became 
apparent when we got into this that the portal that is used for 
the purpose of work by VA staff was not meeting the needs and 
the requirements that existed when you had both Choice and PC3 
running in parallel. We asked the VA staff that does that line 
work to sit down with us.
    We re-architected that entire system: 6 weeks in design, 6 
weeks in build, and fully deployed now. Now people are trying 
to go through the training to make sure that they know how it 
all works. Everything moves through that pipe to the doctor and 
back to the VA.
    That pipe was designed for a specific purpose, to make sure 
that we were solving those problems. The last of the rollout of 
that across the 28 States and the Pacific was about 2 weeks 
ago.
    The second piece is the provider portal. We are in the 
process of taking a look at, with the provider community, how 
we get that to a place where it serves both the Choice side and 
the PC3 side, given the onset of this program.
    I would say, to the question about interoperability, we do 
not yet have interoperability. That is a desire of all of us, 
the VA, ourselves, and Congress.
    As you know from your time in Congress at this point, and 
your other work, interoperability is a hard thing to 
accomplish, but it needs to be pursued and it needs to be 
accomplished in this space.
    As it relates to a contact center in this space, which was 
your first question, that is going to depend on what the design 
is. If the design is that we are simply going to be behind the 
veil and there will be no contact that goes on, then we would 
not place staff here at our own expense. If the design is going 
to be that some portion of that is going to need to be 
required, we will sit with the VA. I will be accountable to Dr. 
Shulkin. I will be accountable to the VISN director for VISN 20 
and the Alaska team to make sure that the tools we design, the 
footprint we put in place, is going to optimally serve it.
    We were moving toward that fast before this hearing, not 
because of this hearing, but before this hearing. We are now 
stepping back. We are going to allow you guys to decide what 
the design needs to look like and then we will rack and stack 
our plan against that.
    We are rolling out local contact centers in every market 
right now. We were just in Nashville on Friday announcing that 
one. We are doing this VISN by VISN by VISN as we scale out, 
because that is the only way to get this right.
    We used to do that in TRICARE. We need to do it here. That 
is why we are moving to that strategy, which was designed 12 
weeks ago.
    The Chairman. I want to change the topic here a little bit.
    Dr. Buck, what are some of the needs that we have with 
regard to physician providers in Alaska? Why are we having such 
a hard time filling that position? How do we relate to this 
broader topic of recruitment and retention? Do we need 
legislative authorization that can enable us to address some of 
those issues?
    To me, that is not a good story. I appreciate that Senator 
Murkowski asked the IG to take a look at it. It seems part of a 
broader issue of recruitment and retention of qualified 
physicians.
    How do we address that?
    Dr. Buck. That is really the key to making things better, 
we believe, in regard to places like the Mat-Su clinic. We 
published a national staffing report that demonstrated across 
the country physician shortages are the most critical need for 
the VA right now.
    The question is how you go about addressing it. Part of it, 
certainly, there will be circumstances in which the VA cannot 
compete with private-sector salaries. A neurosurgeon for the VA 
is going to have a hard time making what a neurosurgeon in the 
private sector can make. The question is, aside from just the 
salary difference, how do we make VA the employer of choice for 
doctors?
    What I can offer you is only my personal opinion. I will 
ask Ms. O'Neill to share hers as well, from having been out in 
the VA and from having seen what we have seen in the IG.
    The truth is that we need to put providers back to doing 
what they do best, which is taking care of patients. If you 
have gotten care in the private sector recently, you probably 
noticed the unwelcome intrusion of a computer screen between 
you and your patient. The electronic health record is a 
wonderful tool but shouldn't we look at voice-activated 
software? Shouldn't we look at other options that make the job 
of a doctor in the VA all about that interaction with the 
patient and not about the paperwork and not about the process?
    If we can make that, we go a long way toward making VA the 
provider of choice.
    How would you go about doing that? Why not spend a day in 
the clinic with a doctor and see how much of their time they 
spend with patients and how much of the time they spend on 
other things. Then from there, bring together your best minds 
and design the best strategies you can to put the doctors and 
the providers back to the task for which they went into 
medicine, which is to take care of patients.
    The Chairman. Dr. Shulkin, do you have a view on that? You 
have been recruiting doctors in the private sector for decades.
    Dr. Shulkin. Well, I would just like to point out that Dr. 
Buck has been a practicing physician, so she shares the exact 
same perspective I have, which is that we have to make this an 
environment where people want to spend their careers. We are 
likely to attract people who are not doing this primarily for 
financial gain. We are likely to attract a large number of 
people who currently work for the VA, who are patriotic, who 
want to give back to those who have served, who choose to be 
there serving veterans.
    I think we have to do a better job of getting that message 
out that we are a great place to work. We do have some issues 
that we have to fix. I like Dr. Buck's suggestions about being 
on the leading edge in making this a place to work.
    If we cannot get the right doctors and other providers to 
staff the VA, we are going to have what happened at Mat-Su 
clinic. We are going to have to just double down on our 
efforts.
    The Chairman. Let me get specific then on the Mat-Su 
clinic. How do we fix that?
    Dr. Buck. After we made our recommendations, the VA 
indicated they have since put in place a permanent provider at 
the Mat-Su clinic. They have a provider now.
    As I said, our work is not done because we are going back 
to see how things are working after that change has occurred.
    The question is more, how do you prevent those gaps? Then 
we get back to the recruitment and retention issues to begin 
with.
    Ms. O'Neill has some suggestions as well, with regard to 
that.
    Ms. O'Neill. Thank you, Senator.
    In our many discussions during the previous report, in 
addition to pay, a couple of other areas for opportunities I 
think to look into: One, provider schedules. So many of the 
providers that we spoke to, particularly here in Alaska, came 
because of the amazing other things that they can do besides 
just see patients. Looking for more alignment between provider 
practice patterns and the schedule that is quite rigid in the 
time and leave program.
    Then just the process itself for recruiting and retaining 
providers, particularly the interface through human resources, 
that it can be slow, cumbersome, with the many regulations. 
Some providers just give up and go elsewhere.
    The Chairman. OK. Thank you.
    Look, I mean, we cannot have what happened ever again, 
right? I mean, it is completely unacceptable. I want to be very 
focused on the issue of recruitment and retention because I 
think, Ms. O'Neill, your point is spot on.
    My own view is that most doctors in the world would love to 
come here. Look at this place. It is a lot better than anywhere 
else in this great country of ours. We just have to get the 
word out and to be able to practice both at the VA clinic and 
maybe with partners like Southcentral. They have a beautiful 
facility out there. It should not only be an opportunity that 
would be professionally rewarding, but living in Alaska for 
most people is personally exhilarating.
    I think we can all do a better job with that. But if there 
are flexibilities that you need with regard to congressional 
authorizations, I am certainly somebody who is going to be very 
open to making sure we do what is incumbent not only on the VA 
but on everybody, which is to fulfill the requirements to have 
the best-trained physicians and longevity treating our 
veterans.
    Well, I am going to close by thanking the panel. Dr. 
Shulkin, I appreciate you coming with the six principles that 
you laid out.
    Mr. McIntyre, I am a little concerned. The point of this 
hearing was not to say, hey, Congress, VA, fix it, we will 
figure it out, right? The responsibility is everybody's. 
Hopefully, that is not what some of your statements were 
indicating, but I got a sense that is a little bit of what you 
were talking about. If you can clarify your view here, that is 
not the goal, right?
    We need smart people to figure out--we have a problem. 
Alaska is unique. The implementation of Choice is not working. 
Thousands of veterans and their families are suffering.
    This whole hearing is about getting ideas on the table, not 
just talking, but acting, and everybody here being part of 
fixing this. I certainly do not want you to take it as some 
kind of mandate to where responsibility is handed over to 
Congress and the VA and you'll step back. You are in. Whether 
you are going to be in for the duration, that is driven by what 
is best for our veterans. I certainly do not want you to view 
this hearing as a pass on the responsibility that you currently 
have.
    Mr. McIntyre. Sir, I am not taking a pass on that 
responsibility. I tried to architect the solutions that I 
thought needed to take place. They are in the process of being 
put in place. I am going to put them on pause until I 
understand what the design is going to look like so that I do 
not end up executing something that is not going to meet the 
need.
    If the need is going to be and that approach is going to be 
a more Alaska-focused approach that goes back to drawing from 
the way that it existed previously, then I am going to have to 
tweak some of the design that I was getting ready to implement. 
That is all I mean.
    I am stepping back so that I can understand what the design 
decisions are, so that I can determine whether I have myself 
properly calibrated, or whether I need to recalibrate. Then I 
will execute and be accountable to you, Dr. Shulkin, the VISN 
director, and the veterans in this community.
    The Chairman. Let me end by emphasizing that point. As I 
mentioned in my opening statement, the VA is accountable. The 
administrators are accountable to Congress. That is the point 
of this hearing, for oversight.
    The main point is that we are all accountable to our 
veterans. I think if we keep that in mind, and I certainly am 
going to do that, then we will not rest. I can tell you my team 
and the members in this congressional delegation, Senator 
Murkowski and Congressman Young, will not rest until, working 
together, we get to a better place. Because right now we are 
not in a good place and we have to fix it.
    I appreciate all of you coming. I appreciate all of you 
traveling from far distances to come to Alaska. I get a strong 
sense that even from a couple days on the ground here, you have 
a much deeper understanding of our challenges and the severity 
of the issues impacting us. I look forward to working together 
to fix that for veterans.
    Thank you very much.
    Again, any Alaskan can submit testimony as part of the 
official record of this Committee hearing, and we will leave 
the record open for this hearing until 5:30 p.m. Alaska time on 
September 1, 2015. We have set up an email address for 
submissions which is [email protected].
    This hearing is adjourned.
    [Whereupon, at 7:48 p.m., the hearing was adjourned.]

                            A P P E N D I X

                              ----------                              


     Prepared Statement of Saket Ambasht, M.D., Pioneer GI Clinic, 
                             Anchorage, AK
    The implementation of VA Choice in Alaska has had detrimental and 
opposite effect on access and healthcare of Alaskan veterans. The 
problems at other VA clinics and hospitals have been well publicized 
and has led to a national call for improvement in VA access and quality 
of care.
    All the while the VA healthcare system in Alaska has been excellent 
with a smoothly functioning system that drew on the civilian reserve of 
subspecialty care. As a matter of fact, three of my VA patients who had 
moved out of state had returned to Alaska citing the quality of VA 
healthcare as the primary reason for their return.
    A national VA Choice plan was implemented across Alaska without 
considering the unusual and unique circumstances that we consider 
routine in Alaska. Over the past 2 years, the VA reimbursement to the 
physicians had dropped 30 percent resulting on significant impact on 
the viability of private-practice physicians. Due to the expensive 
Alaska labor force and the cost of commercial space and attendant 
inflation of conducting business, the entire bulk of reduced 
reimbursements have fallen on the shoulders of physicians. This 
unilateral action has threatened the institution of an independent 
physician, not beholden to the interests of hospital corporations or 
the interests of the insurance companies.
    Adding insult to injury, the implementation of VA Choice has 
resulted in instantaneous reduction of an additional 30 percent 
reduction in physician reimbursements. At this reduced rate, I have 
been unable to provide needed medical services to my patients without 
risking bankruptcy. We are informed by faceless administrators that 
Alaska is no different from Seattle in terms of business climate or 
cost. Of course, none of these people have tried to run a medical 
practice in Anchorage nor have they thrown away substantial amounts of 
money trying to recruit qualified--actually, any--candidate to Alaska.
    For the past 7 years, I have provided care to 1036 veteran patients 
out of 7994 total for a total of 12.96%. Just in the past one year, 
veterans made up 14.53% of my patients. Over the past 2 weeks I have 
been only able to see 2 VA patients out of 77.
    Forced to ration access in order to survive financially, access to 
care for all veterans in Alaska is severely curtailed. I, as a disabled 
veteran, continue to carry private insurance at a phenomenal cost, 
because I cannot rely on timely ``guaranteed'' VA benefits myself.
    I would be willing to testify that this ill-conceived 
implementation of VA Choice program in Alaska has resulted in the 
opposite of the intended effect by decreasing access to care, delaying 
care to the Alaska Veteran population. It undermines the viability of 
physician practices by implementing arbitrary and unnecessary reduction 
in fee for services, threatening the existence of physician practices 
on which Alaskan rely in time of need.
    I write to you to seek redress from this arbitrary decision by the 
VA. Please do not hesitate to have your staff contact me with any 
questions or concerns.
                                 ______
                                 
               Prepared Statement of Anonymous Submission
    As a veteran, I have refrained from using CHOICE as I do not feel I 
should be expected to pay a co-pay for service-connected or over 50% 
rated medical care. I should not need to spend hours on the phone 
trying to establish an appointment. I should be allowed to have some 
say in my health care, whether it be day of appointment (considered 
desired date, or clinical indicated date) or which provider I prefer. 
Patient centered healthcare has been removed by the law to use CHOICE 
and TriWest. You have already heard of the numerous complaints, they 
are all similar. I am not the only veteran delaying my care, or not 
getting the care because I do not want to use CHOICE. Most veterans I 
talk to do not want privatization, and that seems to be the path that 
Congress wants to take. This is something that I have heard of for the 
past several years that Congress would like to do away with the VA. We 
have earned the right to use this system and do not want to lose it. (I 
speak as a veteran, and for other veterans on this matter). If Congress 
wants to enhance the healthcare, it may be necessary, but don't make it 
mandatory and give us options that work. Don't break the system by 
adding more layers. It is not perfect, but don't throw the baby out 
with the bath water.
    One of the reasons vets like to use the VA is it is like family to 
them. It is unique to their needs. As active duty, a camaraderie is 
built. When one separates, they transfer this same camaraderie to the 
VA They like to visit each other, tell their stories, and reminisce. 
They meet with their friends and forge new friendships. When you go to 
local providers, you get impersonal interactions. ``Next'' is 
resonated. They don't always listen to what you have to say. They only 
have a few minutes as they need to see 45 patients during the 
provider's day. They can only focus on one or two issues. At the VA, 
the patient is allotted more time to be able to share their concerns. 
The provider has more time to address numerous issues. Our system is 
bogged down with an archaic records system and numerous performance 
measures we need to meet, but we work through them the best we can. 
Developing a system that actually talks with the DOD, and marries the 
patient records into one system is absolutely necessary. Both the VA 
and DOD have been working on this, but the bureaucracy buried in both 
systems is nearly impossible to get through. With all the technology 
available, you would think we could get through this. We are finger 
printed at every level. Why can't both systems agree to the same 
privacy rules?
    As a VA employee, the nightmare continues. We take pride in our 
service to our veterans. We have about 42% veteran employees at the 
Alaska VA. We serve those who serve. Patients have complained the local 
provider has told them ``PTSD is garbage, don't use that here.'' The 
local providers (includes the PC3 program) will throw in numerous 
consults for follow up care regardless of the need. There is no 
continuity of care. There is no follow through. Patients are needing 
their annual appointment, but no reminders are generated for the 
patient to be aware they are due. Many of our patients have cognitive 
impairments that prevent close following. They fall through the cracks. 
After two years, they fall out of the system as they have not been seen 
in 24months. We have had patients denied care by local providers due to 
behavior issues. Many of these vets are angry with government and needs 
someone who still cares even after getting front line chewed out, 
yelled at, screamed at, etc. The front lines take the heat, and it 
continues on to the exam rooms. It takes skill to diffuse these 
veterans and calm them enough to care for their needs. We aren't always 
successful, but we care and we know that the vet still needs care. Many 
of these behavior issues are due to brain injury. Local providers do 
not have the time or patience, nor the understanding of their anger, to 
be able to safely and effectively care for them. We have a police force 
to help us, the local providers do not. They are for profit, not 
dealing with issues they don't understand. How many more suicides will 
there be if our vets get some of these attitudes from our local 
providers?
    Many of those local providers do not have the psychology back up 
within their system. We can walk across the hall and ask for mental 
health support. We can call our police force to meet us at the exam 
door to help us. We have prevented many suicides just by staying on the 
phone with the vet and guiding him/her to our facility (actual case, 
the MSA stayed on the phone and actually directed him to our clinic for 
immediate care--successful!). We are seriously concerned our patient 
population is NOT getting the correct care due to the system we are 
mandated to follow. The nation is going to a Patient Centered Home 
Based Health Care Model. The CHOICE does not allow that. As for 
TriWest, for every consult they get they get $$ (has been said it is 
$200 each consult). When we manage the consults, and there is one that 
is put in several times for the same complaint, all but the active one 
is discontinued or canceled.
    TriWest does not do that. They just process all of them, getting 
paid for each one, and then the person ends up with numerous 
conflicting appointments dependent on who is handling which consult. 
TriWest admittedly is for profit. Hal Blair stated he would like to 
believe they are taxpayers first, businessmen second. He did not 
mention anything about caring for veterans. It gals us that he used to 
be our associate director for several years before leaving and moving 
to TriWest. He was not effective as Associate Director, and now we are 
to do their job. They are getting space at government cost to have 
their people embedded with us.
    We are spending hours and hours on the phone trying to fix their 
shortcomings. Our employees cannot do the jobs they are hired for as we 
are trying to resolve CHOICE issues. One of our CHOICE experts says the 
average call takes about 35-40 min to resolve. He is chief of service, 
and cannot get off the phones. We are already short staffed in numerous 
departments, and this only adds to the short comings. It is common 
knowledge that ``government contracts are the way to go'' It is a 
business man's dream as the ones at the top get lucrative pay and the 
workers get minimal. We want our job security. We have been hired to do 
this work, and with the addition of TriWest, our duties has doubled. 
This is not cost savings but government $$ wasted. KTOO news is quoted 
as saying ``the government paid TriWest $8.4 million last year to buy 
$2.3 million worth of medical care for veterans.'' That is three times 
the cost of care. TriWest is for profit and it will always cost us more 
as taxpayers, not less.
    Our patients need care managers. We have excellent care managers 
(Integrated Care) and we have some that aren't quite as skilled. It is 
a skill and we try to hire the right characteristics to get the best 
staff possible. A care manager will ensure their patients get the care 
they need regardless of the behaviors, the mental or cognitive 
difficulties they may have. We need to know our patients to be able to 
do this. I will give you another scenario, actual case.
    Patient has a consult for orthopedic care. He needed to go to 
Seattle for the appropriate care and surgery. He has a current consult 
that is still active. At his last appointment it was determined he 
needed additional surgery. He needed authorization for the surgery, his 
date had already been determined for Oct 15. His pre-op was for 13Oct. 
When he asked his Primary Care provider for the request for 
authorization, a second consult was entered (not needed as he was still 
authorized care on the first consult). He was given a new appointment, 
but this was for an initial exam. He did not need the initial, only the 
authorization for the surgery. He could not get it, He was told this 
was a new consult and he would need to see a surgeon to determine need 
for surgery. We have been working with this vet since June to resolve 
this.
    I spoke with him a week ago, and still no resolve. To add to his 
frustration and need for numerous calls and being on hold for hours, he 
has some brain injury which affects his memory. He is unable to 
remember more than two tasks at a time, and there is no care giver to 
follow this to ensure he is able to avenue the system. He may forget to 
get the MRI scheduled, or not make the correct travel arrangements, 
etc. He told me he plans to have the surgery regardless if he can't get 
the authorization in time. And the VA can figure it out later. Does 
this mean he will get $$$$$$ of bills?
    Another case: Patient needs MRI before our orthodontist can see him 
for his first visit. He lives in Juneau so he needs to get the MRI at 
the local hospital. We have a Physician Assistant that is working under 
a Washington State licensure. They are denying her orders as she is not 
licensed in Alaska. (As a Federal employee, we are allowed to work 
under our state of licensure without having to apply in every state we 
happen to work in or are stationed as active duty). So the staff has 
had to find a provider that is licensed in Alaska. However, this 
creates more problems. The provider ordering is responsible for the 
results. The Primary Care provider is a Nurse Practitioner and has a 
license in Oregon. Again, not accepted. His surrogate is not willing to 
sign the order. The general surgeon is not the care giver.
    Around and around we go, and we eventually had to cancel the 
consult as we cannot see him until we the diagnostic results. The 
patient is angry, we are frustrated. The patient is in pain and needs 
treatment. Our local vendors have been able to work with our staff and 
resolve these issues with the Non-VA Care Closer to Home initiative. 
TriWest has not been able to do that. Another case: I spoke with a 
vendor (happened to be a caregiver for me due to a vehicle accident, 
other driver at fault). Asked how the CHOICE program was working for 
them. She said it is very confusing, and the ``right hand does not know 
what the left hand is doing.'' ``We are having to reshuffle all of our 
accounts. Makes it tough.'' Other vendors are canceling their 
agreements with the VA and opting not to use TriWest as they have had 
issues with this agency in the past. Agreements that were working very 
well are now lost.
    Our Rheumatologist had to leave our employment due to her spouse 
PCSing (change of duty station). It took us about three months working 
with the local Rheumatologists to set up patient care for her 450 
patient panel. All Rheumatologists locally have a 6-12 month wait list, 
and we were able to work through this backlog and ensure patients were 
seen when their clinical indicated date was due and no or minimal delay 
in care occurred. As soon as this was resolved, TriWest came in and all 
this was lost. Vendors were dropped or chose not to participate, and 
now we do not have readily available providers for follow up. We will 
not be hiring another Rheumatologist as they just aren't available.
    We have had vendors give inappropriate care as they get paid better 
for the different codes. One podiatrist was giving joint injections as 
treatment for a condition the patient did not have. He did not have 
joint pain, he had a different diagnosis, but for each injection (10) 
the provider was paid for each one, costing the VA thousands of dollars 
for the one visit. This was identified by our staff, and was well 
documented, so our leadership was able to determine this vendor was 
rendering unsafe care. There have been other examples of this type of 
fraud and misuses of diagnostics for patient care.
    There is no urgency considerations for consults. Any consult less 
than one week is batched with all others. Our Chief of Staff is needing 
to go through each one of the urgent consults to determine if the 
urgency is appropriate. If it is, we need to try to find a vendor able 
to see the patient and hopefully wait for payment when we get some 
funds to pay for it. This includes any patients not eligible for 
CHOICE, or those who had their treatment halted (cancer therapy, PT, 
etc.) due to CHOICE. This had become a full time duty and she is unable 
to give full attention to her regular duties as Chief of Staff.
    Patients are now being asked to wait longer than the 30-day window 
in which we were already doing well in getting most patients seen 
within 30 days. I was told by one patient that when he called TriWest, 
after numerous calls and different staff giving him different answers 
with each call, he was told 'we only upload the consults once a week. 
(one week delay), then we have 6-15 days to work the consult (three 
weeks), and the appointment may take up to 30days to be seen, Almost 
two months. I had one patient that called the vendor and said they 
could see him the same week. He called TriWest and was told the vendor 
(same one) did not have an appointment available for 45 days. Same 
vendor, same day he called.
    For our hiring issues: We need to be able to pay our staff 
appropriately. I understand the need to cut the budget, but don't do it 
at the bottom of the pay scale. Our classifications department (VISN 
level) is reducing nearly every position by a pay grade. An MSA 
answering the phones and doing clerical work is paid at a higher level 
than the health technician (HT) level for a job description that I 
submitted. It was downgraded to a five, and the MSA is a six. The 
health technician takes a life in their hands, doing direct patient 
care, identifying serious health issues and concerns, and keeping our 
providers on track to get our patients seen timely.
    In Alaska the cost of living is very high. I cannot hire staff for 
minimal pay. They will go elsewhere. I was told by a senator, ``We have 
to cut the budget somewhere.'' At the cost of some of our hardest 
working staff. They stay because they are committed, not because they 
are paid well. As I need to hire health technicians, I submitted a Job 
Description, following the classifications guidelines and personal help 
from the classifiers. When the position was reduced from a six to a 
five level (title-5) I was told they compared the HT with a certified 
nurse assistant (CNA). That is equivalent to comparing a nurse 
practitioner with a medical doctor. If they use this same analogy for 
comparison, then the MD should be paid the same as the NP, as both are 
doing the same job in the clinic. No distinction other than pay. One is 
under medical practice, the other is under nursing practice and follow 
different regulations. A CNA (nursing practice) cannot do certain tasks 
that a HT (medical practice) can. They are two different requirements.
    I need HTs, not CNAs. I myself was a CNA, so I know what the 
Nursing regulations are. When I rewrote to add duties and give the HT 
more responsibility, I was told their work still did not warrant a six 
level. But a front line clerk did. (I do not want to take away from 
them, as the front line takes a tremendous amount of heat from our 
veterans, and earn every dollar they make, but our health techs are 
health professionals in direct patient care. They dress wounds, assist 
the providers, take orders, work specialized equipment, etc. I then 
rewrote the description to match a surgical technician, knowing that I 
would be able to cross train them for the OR as well as assist with 
procedures in the clinic, I was told that they did not believe that 
their work warranted the same level as the surgical tech in the OR.
    These classifiers are not working in the health field but are 
administrative deciding what they think the HT or surgical tech 
actually does. For the providers, some considerations for recruitment: 
If we hire the Uniformed Public Health Corp, they can only work for six 
weeks. Not worth the time to train. This is a service that once was 
able to work within the Indian Health Services, but here in Alaska, 
that is no longer the case. Lose the bureaucracy, and make it easy to 
utilize another government service by allowing the VA to hire this 
service full time.
    As the DOD is trying to downsize, allow some of the active duty 
that want to continue their careers to work in the V A as active duty 
to complete their service. In year 2001, a commander for the hospital 
PCSd to Mt. Home, Idaho. His wife was also active duty urologist. Mt. 
Home did not have a position for Urologist, but the VA was able to use 
her. Her active duty assignment was carried out at the VA. A win for 
both the DOD and VA as well as the military member. So, I know it can 
be done.
    Pass some sort of legislation that allows us to hire and pay back 
some tuition as they do in the military. Consider well-trained 
providers (trained in England, and America for example) that have not 
yet received citizenship. One very qualified individual had the 
training, but could not get hired due to citizenship. For him it was a 
catch-22. I can't quite remember his dilemma, but to get one, he had to 
hire, but couldn't hire because he didn't have the fellowship. 
Something to that effect.
    I hope the intent and information in my letter is useful. I could 
add more cases, but you already have the facts to see that this system 
is not working. Key points are looking at recruitment, looking at how 
they classify positions, and not privatizing (will always cost more and 
leaves the door wide open for fraud and waste). If you need additional 
information, please do not hesitate to get a hold of me.
                                 ______
                                 
       Prepared Statement of Ms. Elizabeth Bacom, Petersburg, AK
    I am writing as a veteran, with numerous veterans in my family as 
well as a son serving active duty. In my work, as the manager of a 
clinical laboratory in Southeast Alaska, we have numerous veterans 
coming for laboratory or imaging studies. In the past (prior to VA 
Choice), we would receive a fax authorization that provided a range of 
dates for service to be rendered. We made every effort to contact the 
veteran so he/she could come in for testing. With the new VA Choice, we 
often do not have an authorization prior to the patient coming in, and 
when we do have an authorization, it is only valid for ONE DAY.
    For outpatient lab work, a veteran may need to fast, if this factor 
is forgotten, a new authorization needs to be obtained. This program is 
not adequately meeting the needs of our veterans, and there is much 
confusion for providers. The VA needs to communicate with clinical 
providers to learn the impact of this program. The only way to improve 
this program is to involve veterans AND agencies that provide care like 
the hospital in our community. I have many suggestions to alleviate 
frustrations for everyone. Assign case managers to regions and make 
sure they understand the region they are covering. Someone in Texas 
does not have a clue to the issues in the difficulties of 
transportation between remote Alaskan communities. Open the dates for 
the authorizations.
    Use a ``credit card'' that can be loaded electronically with 
authorizations to pay for services. Our service-connected veterans 
(SCV) have the same difficulty as our non-service-connected veterans. 
These two groups need to be isolated, not treated the same. Often the 
SCV has medical issues that need to be followed more closely. I am 
always pleased to take care of a veteran. Today I had to turn a veteran 
away because I didn't have the authorization. I called the VA Choice 
line and am waiting for a return call. We can do better for our 
veterans! I am happy to discuss this further with you or an assistant. 
I am not enrolled in VA Choice because I have adequate care and don't 
need the additional medical coverage. There are veterans that need this 
assistance, it should not be rocket science to get them the medical 
care they need and deserve. Thank you for taking the time to read my 
message.
                                 ______
                                 
   Prepared Statement of Brian S. Beard, (US Army, Service-Disabled 
                         Veteran), Sterling, AK
    FIRST OFF I would like to state how very grateful I am for the 
assistance and services I receive as a Veteran. I do have experience 
with the VA Referral process (pre- and post-VA Choice Program 
implementation) and want to provide insight from one Veteran's 
perspective as to possible issues and areas I see where improvement may 
be helpful. I would be open to assisting with the improvement of this 
program or any other area in need.
Summary:

    I had a couple of referrals prior to the VA Choice Program 
implementation and three since that program was implemented. I will 
list the general areas where I have experienced issues and/or believe 
some level of improvement may be warranted. Feel free to contact me if 
you have questions or if I can be of assistance in improving this 
program or any other area.
    1. Confusion re: purpose and when to use program. I received 
multiple letters prior to the program; however, I never really 
understood if it applied to me since I already received all my health 
care through the VA. I also received at least 2 ``member'' cards for 
the VA Choice Program. The latest one I received is marked ``Temporary 
Program.'' It wasn't clear to me that ALL referrals had to go through 
this new program (at least the ones where the VA is referring services 
out to a non-VA service provider). There is, however, no indication to 
me as the Veteran that a given referral will be met from service 
providers within the VA or external to the VA--different processes? For 
the referrals that are supposed to go through the VA Choice program, 
the process does not appear to be understood well by those who are 
involved (VA and VA Choice Program personnel).
    2. Overall process confusion: In my experience the overall process 
and associated timing of each step is not well defined (at least it is 
not well understood by those the program serves--in my opinion). There 
are several layers and organizations involved at different times: local 
VA service provider (submits initial referral), VA (enters referral so 
VA Choice Program can process referral), VA Choice Program (actual 
processing and funding for referral and making appointment), external 
service provider (ah, the actual appointment), VA Travel, etc. The 
process just seems complicated and ill-defined; moreover, there is 
terminology that adds to the confusion when speaking with different 
organizational representatives: referral vs. consult, approval, 
funding, etc.
    3. The VA Choice Program adds another layer of people involved with 
processing referrals. I believe there is an issue with the interface 
between the VA and the VA Choice Program. VA personnel have not 
received training on how to properly process referrals (at least the 
ones I have spoken with), there are no processes in place to confirm 
entered referrals were actually received and processed by the VA Choice 
Program, and Veterans are subsequently left hanging with no 
communications in many instances. For example, a local VA care provider 
entered a referral for me in mid-May 2015 (for neuro/psych testing). I 
never heard anything so I contacted the VA Choice Program a couple of 
months later and wasn't able to get an appointment until late July. I 
only got the appointment because I made several calls and found out the 
referral hadn't been processed correctly.
    4. Processing by the VA Choice Program is quite slow and drawn out. 
Not only is the overall process slow, but I have had to call multiple 
times for each referral. For example, I called to confirm they received 
the referral /consult from the VA; then I had to wait and call back for 
approval and funding to be provided--at that time I have to give them a 
list of availability dates for appointments * * * and then call back 
later to obtain actual appointment details.
    5. Communications from the VA Choice Program concerning referrals 
and associated details are almost nonexistent. I have had at least 
three referrals for care since the implementation of the VA Choice 
Program, and I have had to contact them in almost all my dealings to 
obtain details of appointments, etc. (I actually don't think I have 
ever had an instance where someone from the VA Choice Program has 
contacted me proactively with information concerning my referral or 
appointment)
    6. Making related appointments (based on referrals): It would be 
very nice to have the option of having VA Choice Program personnel make 
an appointment for me OR allowing me to call the actual service 
provider and make my own appointment (after approval has been provided 
to care provider from VA Choice Program).
    7. Accuracy: I had one instance where I was told by VA Choice 
Program that I had an Allergist appointment on a given day at a 
specific time. I showed up to the Allergist for my actual appointment 
and was told I didn't have an appointment. The receptionist stated that 
she had spoken to someone at the VA Choice Program but was expecting a 
call back for something needed for finalization--and never received 
that call back.
    8. Related Travel: There is also a disconnect between the VA Choice 
Program and the VA concerning travel associated with an appointment 
resulting from a referral. No information is provided on handling 
related travel (not always needed, but it is sometimes). This leaves 
the Veteran not knowing what to do or who to contact to address any 
travel needs. I was told by the VA Choice Program representative that 
they do not handle travel at all, so I needed to contact the VA for 
that; however, I did not have a contact or number.
    9. POSITIVE: The VA Choice Program representatives have always been 
nice and respectful in my interactions with them.
                                 ______
                                 
 Prepared Statement of Diane Carlow, Billing, Kenai Peninsula Medical 
                           Office, Kenai, AK
    I am not a veteran, but I am affected by the changes, NOT for the 
better, that the Veteran's Choice program has instituted. I am the 
biller at a Kenai Peninsula medical office, and I have found the new 
Choice program to be much more difficult to navigate and deal with than 
the old VA program. Veteran's Choice is making the regular VA billing 
and payment system look positively angelic, and it was by far the worst 
program with which I dealt prior to the Choice program. The old VA 
system was the slowest payer; I repeatedly had to tell the doctors that 
it would do no good to even question an unpaid claim that was less than 
two months old as it would not have been far enough through the system 
to even discuss with anyone. The vast majority of our electronic claims 
to any payer are paid within two weeks and our paper claims (other than 
VA) are paid within a month, with rare exceptions.
    That said, our medical assistants had found a contact person in the 
VA with whom they could speak and be assured a requested authorization 
for a patient's surgery or further treatment would be coming in short 
order. I, too, had a contact in the billing department to whom I could 
fax unpaid claims and she would investigate them and push them through, 
or kindly tell me what the holdup was so I could correct the claims 
into a format that the VA would recognize. Often that format was more 
stringent and less logical than even Medicare as far as their ability 
to understand and extrapolate information and pay accordingly. I 
frequently got faxes to send a corrected claim only to find out the 
claim in question had already been paid months earlier because they are 
apparently unable to see claims that may have paid on a different 
authorization number (the suffix of the authorization was different, 
not the entire authorization).
    I cannot speak about the payment system for VA Choice because, as 
of yet, we have not been paid for any VA Choice invoices. Our first 
claim to Veteran's Choice was mailed in mid-June, but most of them are 
from early in August. Additionally, with the old VA system, I simply 
needed to mail claims and medical records to the Anchorage address of 
the VA and they were scanned to the appropriate office. With Choice, I 
have to fax the medical records and then mail the claim and records, an 
added burden on medical offices in terms of time spent on each claim. 
There are also restrictions on waiting room times and other burdens for 
our office. Since our doctors are on-call at the local hospital, 
waiting room times cannot be guaranteed for any patient, although we do 
our best to be prompt, emergencies do happen which can delay patients 
seeing the providers on time.
    We offer to reschedule patients who are unable or unwilling to 
wait, but that change of appointment time can compromise the veterans' 
Choice authorizations. Our doctors are considering turning away VA 
patients if the system does not improve. That would result in a lack of 
choice in providers which is exactly what the Choice program was 
supposed to alleviate.
    When we, as an office, had the ability to preauthorize further 
treatment for a veteran who had an initial authorization from the local 
VA Clinic for treatment with us, treatments were usually started in a 
very short time. Now with Choice, the veterans are being told they need 
to get everything preauthorized and that we, as an office, cannot do it 
for them. There are very few veterans who are medically savvy enough to 
understand treatment codes and diagnoses to successfully request 
authorization for further treatments. I have had a few of them call me 
for CPT coding for potential surgeries, but I imagine most just throw 
up their hands in frustration. I understand that we can ask for a SAR, 
secondary authorization request, but the TriWest representative who 
came to speak to the office a few months ago told the assistants and 
office manager that ONLY the veteran would be able to request 
authorizations of any kind. At the very least there is a disconnect or 
misunderstanding about how the system is supposed to work for treatment 
beyond the limited visits and x-rays that are routinely authorized by 
Choice for our veteran patients.
    I guess what I am trying to convey is that although the old VA 
program was by far the worst with whom we dealt, the Choice program is 
much worse than the VA ever was. I urge you to fix the system(s) to 
better serve our veterans.
                                 ______
                                 
            Prepared Statement of Tom Carter, Fairbanks, AK
    The VA system of healthcare worked fine in Alaska before the choice 
card went into effect. The best way to fix the program in Alaska is to 
reset, go back to what we had before and Scrap the choice card 
altogether.
    Simple fix, great results, no problems for us or VA after that.
                                 ______
                                 
      Prepared Statement of Jerry Farrington, Kenai Peninsula, AK
    I was not able to testify at the hearing you held in Kenai on 
August 24, 2015. The following is what I would have told you.
    This past Saturday I tripped and hurt my right shoulder and ended 
up in the emergency room of Central Peninsula General Hospital. One of 
the ER doctor's recommendations was to see a specialist in a timely 
manner.
    Monday morning I spent almost 1 hour talking to the nurse at the 
choice program and was granted approval and that she would forward my 
approval to scheduling and they would get back with me in 7 to 10 days. 
Now I do not consider 7 to 10 days or more to see a specialist to be 
``in a timely manner.'' That I expressed to the nurse. I was told that 
he 7 to 10 days is what they are allowed and that they did not have to 
respond till then. The normal Orthro doctor I have seen in the past did 
not have any openings until Sep 9. 18 days after I injured my shoulder.
    After having to deal with the Choice folks in the past, I have 
become a hands on person and I called the other 2 Orthro clinics in 
town. They both had openings for Thursday , August 26. I relayed that 
info back to Choice and was on the phone again for almost 1/2 hour 
giving them the clinic name, location and date of the appointment. As 
of today that appointment has been approved.
    Once I am evaluated, I expect additional test to be requested. 
Again being a hands on type of person, I will make arrangements for my 
test to be completed, so they can fill in the blanks while I sit on the 
phone for another hour or so.
    I ask you the following questions:

     Why must we do their work for them? And if we don't, we 
sit here waiting for days and weeks for an appointment. They have no 
local knowledge on what or who is available or services provided.
     Our local VA clinic has a better understanding of local 
services and are more than capable of providing approvals for services 
that they cannot provide.
     If services cannot be provided locally in a timely manner, 
why is it not suggested or asked if the veteran is willing to travel to 
Anchorage for treatment.
     What services does the Choice Nurse provide in granting 
approval that any local doctor or VA clinic could not provide in a more 
efficient manner. After all they either have evaluated the patient or 
has their current records in hand.
Recommendations:
     If you are going to keep the Choice program, allow local 
VA clinics to authorize and schedule appointments for services they do 
not provide or in cases where the workload exceeds the manpower. 
Provide the clinic or facility with a voucher for payment.
     Local medical treatment clinics etc. may be filled to 
capacity and when this happens, the veterans should be advised and 
given a choice of where to seek treatment. Timely to staff may not be 
considered to be timely for the patient.
Additional comments:

    On August 5, 2015, I had an appointment with my VA Doctor. He 
requested an x-ray. That request was sent to Anchorage and after 
several days the request was sent on to Choice. I was instructed to 
contact Choice once the request was received. That I have done. Again 
their response was that they will get back with me in 5 to 7 days. 
Today is day 7, and I have yet to hear from them. The same goes for the 
physical therapy appointments that were requested.
    It is my opinion that if you want the Choice program to work, you 
have to do all the work for them and allow them to fill in the blanks 
on their forms. That can be done by any elementary school student.
    Thanks you for this opportunity for me to express how the Choice 
program has been working for me specifically.
                                 ______
                                 
         Prepared Statement of Jim Fassler, Kenai Peninsula, AK
    Thanks for providing a way for veterans to get the message to you 
that the choice program is a failure.
    I was one of the few at the Kenai meeting that observed the 
``stop'' sign after 3 minutes. I was unable to finish my talking 
points.
    We have a fine ophthalmologist practicing on the Kenai Peninsula 
that will not accept VA patients. I talked with his staff & was told 
that he probably would accept the payment offered by VA but the check 
never comes. I can't find fault in this professional not wanting to 
work for free.
    Also, the optometrist (Eyeware Express) in Soldotna is considering 
no longer working with the VA system because of the amount of payment. 
His fee is $150 for an eye exam & payment is $90. Again, how can this 
professional survive on payment that is less than his cost of doing the 
exam?
    Our CBOC has recently experienced the loss of one of two front desk 
personnel. Since that time, I understand that a replacement is being 
recruited but has not yet come to work. It is not fair that one person 
is expected to pick up the slack AND also not fair to veterans that 
cannot have the phone answered in a timely manner. The voicemail system 
in place delivers messages somewhere between several hours and several 
DAYS after we leave messages.
    IT IS TIME TO GET A REPLACEMENT FOR THE EMPLOYEE THAT LEFT DUE TO A 
PROMOTION!!
    There was mention that no VA employee has been fired after the 
Phoenix and other disasters. I hope that when you are allowed to fire 
these people for not doing the job they are paid to do that you will 
put a ``NOT FOR REHIRE'' notation on the personnel file. It is 
offensive to me that employees fired for cause should be rewarded with 
another government job. If they couldn't do one job, how do you expect 
any better in another position--probably with a pay increase?
                                 ______
                                 
  Prepared Statement of Dorothy Ferraro, Director, Public Relations, 
                        South Peninsula Hospital
    First off, a few thank yous: Thank you to the many veterans in the 
room for your service. It's an honor and privilege to be with you 
tonight.
    Thank you to Senator Sullivan and his staff for the opportunity to 
share important suggestions to improve the VA Choice program.
    And thank you to the VA for offering the VA Choice program. The 
concept is a great one to open the doors in the rural areas for the 
veterans to take advantage of local offerings, keeping them safely in 
their communities for their care, and supporting the local physicians 
and healthcare providers.
    I could sit here for hours talking about how patients are affected 
by problems with Choice. How veterans wait weeks for critical 
procedures, or pay out of pocket for prescriptions because they still 
have no answer after weeks of waiting, or wait for over a month for 
authorization of pre-surgery labs, which can delay or postpone their 
surgery. But they will tell you their stories.
    Instead, I'll give you the perspective through the eyes of the 
hospital. We are a small, critical access hospital which offers a full 
range of ancillary services, specialty clinics, and primary care. 
Veteran's coverage is a growing payer for our organization, 
particularly due to the development of Choice, increased outreach and 
marketing the VA is doing to enroll veterans into the benefits they 
have earned, and the fact that we host the Kenai VA Clinic three days a 
week. We want to do business with you, but right now it is a challenge.
    The first problem is LACK OF INFORMATION:

     VA repeatedly tells veterans that we are not an approved 
provider, though we are.
     Nobody knows how to quickly and easily find out what's 
covered or quickly obtain authorizations.
     It's hard to find out where to send our claims and if 
regular VA or the Choice plan is responsible.

    The remaining hurdle is that CHOICE IS NOT USER FRIENDLY AND A 
LITTLE DISORGANIZED:

     The VA Web site only allows providers to look up 
authorizations once per day. Once you've logged in and searched for 
your authorizations, the system logs you out and won't let you back in 
later in the day. This is unfortunate because things might change from 
the morning you cannot see it. If this Web site functioned better it 
would reduce your need for customer service reps, and our time spent on 
hold.
     Approval times for Choice services are very slow which 
makes it difficult to schedule; we have had to cancel surgeries & other 
procedures and are now reluctant to advance schedule.
     Choice customer service reps are not very knowledgeable 
and are not helpful; Choice staff needs more training.
     The Choice Manager actually told us to bill for services 
that we were not provided because they were the ``authorized 
services;'' and said it wouldn't be fraud on our part because VA Choice 
is not an insurance company! So most of the visits in the primary care 
clinic are being authorized using a wellness code, when in reality the 
patient is being seen for a focused problem.
     Your Authorization forms all look the same, are difficult 
to read, have a lot of clutter and have the important parts buried: who 
the payer is AND what is approved. Improve the authorization forms.
     Expected payment time is unknown and unreasonable. Our 
primary care has billed 13 visits over the last 6months, but haven't 
been paid on any of them yet.
     Secondary authorizations in our Rehab for extension of 
treatment are not responded to. They claim they don't receive them; 
this totally interrupts patient therapy and is a nightmare for our 
scheduling. People schedule their PT in advance--not possible for our 
veterans; Choice says it will take up to 10 days, but we always have to 
call them after two weeks of no response.
     VA Choice and VA do not communicate; we have to call one, 
wait on hold forever; then learn you have to call the other; after just 
having spent over one hour total just waiting on hold. They act as two, 
non-related entities, with no obligation to cross reference. VA might 
approve four visits, but the Choice has to do the remainder, but choice 
knows nothing about it. It's totally starting from scratch.
     VA Choice called to set up an appointment for a patient; 
they sent us the patient info, and we called the patient realized they 
lived in Soldotna (80 miles away); they obviously said they would 
prefer Soldotna for treatment so we shredded their authorization. A few 
days later the patient called us to request a copy sent to them because 
VA Choice could find no record of the authorization.
    South Peninsula Hospital appreciates our partnership with the VA. 
We appreciate VA Choice, we want to see it succeed, and when 
functioning properly it is a win-win for the providers and the 
patients; we hope you can use our feedback to make positive 
improvements. Thank you for your time.
                                 ______
                                 
  Prepared Statement of Graham A. Glass, M.D., Peak Neurology & Sleep 
                      Medicine, LLC, Anchorage, AK
    Choice doesn't serve the veterans well, which you have heard from 
the veterans currently on many levels. It also doesn't serve providers 
well which has already resulted in significant access problems and most 
importantly, it has resulted in access problems with the highest 
quality physicians. The busiest physicians are full in Alaska and 
aren't necessarily willing to deal with another poorly constructed 
layer of authorizations.
    For example, I have already been made aware by patients that the 
premier neurosurgery group in town will not see ``choice'' patients. 
This has also been the case with neurological consultants of Alaska 
which is a competing neurology group. The reasons are many and include 
payment issues, difficulty with obtaining meaningful and timely 
authorizations, complexity with billing private insurance if the 
veteran has any with obscure rules for using choice as a secondary 
insurance. My staff has told me that we need an entire FTE to deal with 
``choice.'' This is unacceptable and will result in us and other 
practices closing out veterans which is not fair to them. They will 
then have the ``choice'' to receive care at offices that are not booked 
out, less well respected in the community and ultimately result in 
lower quality care for veterans at what likely isn't a cost savings.
    In order to remedy these issues I would suggest considering the 
following plan:

    1) Feel free to leave ``choice'' as an option for veterans who 
don't want to use the VA system up here
    2) Modify choice to actually allow reasonable access. They need to 
provide adequate records to review for physicians, need to have 
reasonable authorization procedures and most importantly need to 
function as the primary and only payor for the veteran. Having to sort 
out primary vs. secondary payor issues is very tedious with choice and 
further sorting out copay issues is frustrating and veterans get very 
angry if they have a ``copay'' which is something they have never 
encountered. For providers, we are very used to dealing with primary 
and secondary payors, but with no other program does the secondary need 
a prior authorization. every other secondary follows the lead of the 
primary insurance.
    3) Reinstate the use of the Anchorage VA ``ICS'' group and fund 
them well. Almost all providers who work with veterans have a great 
relationship with that team and this team had been providing good 
service to veterans. They are easy to work with, are very reasonable 
about prior authorizations and look out for the best interest of the 
veteran by sending them to docs in town with good reputations. Most of 
the time when access issues occurred before it was related to the 
community office being booked out or limited funding to this team.(for 
example if you call my office for an appointment. today and have the 
best insurance in he world but are not an emergency, I'm booked out 3 
months---you can go to another neurologist sooner, but the only ones 
that aren't booked out are the locums that come up to a competing 
practice and are not invested in your community or long term care).
    4) Give the veterans a ``choice'' to choose the choice program or 
the VA system here that actually worked pretty well considering the 
many unique challenges to Alaska.
                                 ______
                                 
          Prepared Statement of Donald W. Heckert, Nikiski, AK
    Over the past three years, I have waited 17 months for a prescribed 
MRI, have been scheduled two appointments in the same time for the same 
day, but over 120 miles apart. When notified of the second appointment 
1 day prior to it being scheduled, the VA stated the reason is the 
scheduling computers don't connect with each other.
    Similar issues occur during requests for travel. I was denied 
filing travel mileage at my local clinic, for travel to another VA 
hospital over referrals my clinic's supporting hospital scheduled.
    My treatment records were forwarded to Fairbanks, and I hand-
carried copies and provided copies. Fairbanks is a joint DOD and VA 
community hospital. I was directed to contact Anchorage. Since I am a 
retired USAF veteran, I attempted to get my medication from the 
Military Pharmacy at Bassett (60 feet down the hall) and was told that 
they could not honor VA prescriptions. I received a call from Anchorage 
VA a week later on the 13 July. I have called Choice three times now 
with no response. In order to receive treatment and prescriptions here 
at Kenai, my physician cannot work with me until I have gone through 
orientation (my Kenai records were still in the computer in Kenai) now 
scheduled for 2 September at the earliest.
    Please help direct the System to respond in a timely manner to 
ensure access to care for all vets, and improve access to 
prescriptions. I have been advised it would be easier for me to stop 
work, leave Alaska, and return to my VA in my previous home state.
                                 ______
                                 
         Prepared Statement of Emmet Heidemann, Eagle River, AK
    Last night I thought it would be a Town Hall meeting and I wanted 
to inform you how The Choice program was working in Alaska. I was told 
there would be no public comments at this meeting.
    I was approached by the TV reporter and I explained my experience 
to her. I was emailed a copy of this article and I noticed you were 
looking for solution to the present no service of the Choice Card.
    My suggestion is to have the VA in Anchorage solve this problem for 
Alaska. They have been doing miracles with an undermanned and under 
funded program for years, I have full confidence with their knowledge 
and leadership they can make a system that works in Alaska.
    The entire authorization program was being worked by 3 people now 
we have an empire replace 3 people working out of the Anchorage VA. 
Bigger is not always better.
    Local knowledge of location, weather, and its people that is what 
makes a system work, there is an old saying ``We do not care how they 
do it outside we live in Alaska.''
    I am speaking for myself and other veterans, we thank you for 
interest in veterans being treated fairly and representing us in this 
huge government. You have our support.
                                 ______
                                 
                 prepared statement of dan j. kosterman
    I am a disabled veteran and a healthcare provider. I use the VA for 
my health care. The recent change to the veteran's Choice Program has 
been a nightmare for me.
    I suffered an aggravation of a previous injury. I called the VA for 
a referral to a chiropractor, to whom they had sent me previously. I 
was told I had to join the Choice Program.
    There was a wait of almost 2 weeks to get that straightened out. 
Then I was told that my provider was not a member of the Choice 
program. It would take a month and a half at least to get him enrolled.
    I ended up paying for care myself. I was unable to work due to my 
injured condition. My chiropractor was frustrated by repeated attempts 
to get authorization for my care, once he was an approved provider (no 
one informed him that he was finally approved. I had to call the Choice 
Program to confirm, and then I informed him). Took several weeks until 
someone at the Choice program finally mailed them an authorization for 
my care.
    As a provider, it has been very frustrating trying to get paid for 
the care I have provided. It is routine to get any email stating that 
we never sent in our report, even though we had documentation that we 
had, indeed, sent it.
    The system that existed before the Choice Program was somewhat 
cumbersome, but at least it worked. I have heard multitudes of 
complaints from other veterans about the runaround they have received 
the choice program.
    Please do everything you can to restore the VA/TRICARE program to 
its former state.
                                 ______
                                 
Prepared Statement of Pat Linton, Executive Director, Seward Community 
                       Health Center, Seward, AK
    Thank you for hosting the listening hearing on this issue this past 
week. I attended the session in Kenai, but time ran out before my name 
was called to testify in person. Consequently, I am submitting my 
points for your consideration through this email as you encouraged us 
to do at the session. I was a Congressional appointee to Annapolis. I 
then served seven years in the National Guard. My father was a naval 
veteran in WWII.
    I serve as the Executive Director of Seward Community Health Center 
(SCHC), a non-tribal FQHC that opened in March 2014. SCHC was created 
by the city of Seward in 2010 and was successful in receiving its New 
Access Point 330 grant award in late 2013. In our situation, the city 
of Seward is technically the grantee, and the health center is operated 
by Seward Community Health Center, Inc., an Alaska non-profit 
organization established for this sole purpose. Thus, we work in a 
partnership relationship with the Administration and Council of the 
City to bring sustainable, affordable, quality primary care to the 
people of the Seward area.
    Since our opening, the topic of how best to serve the veterans 
residing in and visiting the Seward area has been one of regular 
attention. We are keenly aware of the high per capita ratio of veterans 
in our service area. When the VA Choice program was first announced 
last year, we were on top of it as soon as possible. We have been 
serving veterans under this program since last November even while we 
were negotiating the contract. We have served 13 VA Choice veterans so 
far and hope to continue growing this number. Although we, too, have to 
deal with the challenging administrative authorization and reporting 
procedures currently required to participate as a provider in this 
program, we have learned how to do so as best we can and seem to have 
been able to develop a relatively good working relationship with our 
counter-parts at TriWest.
    We recently hired a board-certified family medicine physician who 
serves as our Medical Director. Prior to joining our team, he served 
for 17 years in the Air Force and completed his service as a Colonel 
and head of Aerospace Medicine at JBER this past April. We have 
veterans who serve voluntarily on our Board of Directors of the health 
center. 92% of our Board members are also patients of the health center 
so we are truly patient-directed in service to our community.
    We have two family medicine physicians and a family medicine 
physician assistant on our permanent provider staff. We also have two 
RN's, one of whom provides patient health education, case management 
and care coordination services. We also have a social worker on staff 
who coordinates all of our outreach and enrollment services and is our 
primary point of contact with TriWest for this program. We also have 
close working relationships with SeaView Community Services (behavioral 
health, substance abuse and disability services) and Chugachmiut 
Northstar Clinic (tribal clinic, but not an FQHC), both of which are 
located here in Seward.
    We are a provider a comprehensive, primary care services to 
veterans and all members of our community regardless of ability to pay. 
We offer a sliding fee discount program to those who are eligible and 
in need. We take all forms of insurances and third party payment. We 
often set up payment plans for those in need. By Board policy, we do 
not send anyone to collections. We also have same-day appointments 
available every day so that any patient is able to get in to be seen 
either that same day or the next morning without having to wait. We are 
co-located within Providence Seward Medical Center with full service 
laboratory, radiology and emergency services literally across the 
hallway from our clinic.
    We were able to successfully negotiate and execute a contract with 
the VA Choice program about ten days ago. We have the capacity, 
capability, competencies and sincere intention to serve as many local 
veterans who come to us for service under the program as needed.
    Like yours, my heart went out to our veterans who courageously 
provided horror story after horror story at the hearing in Kenai. On 
the drive home, I could not stop thinking of ways we could help make it 
better for them. A number of creative ideas came to me about how we 
could quickly design and implement a two-year demonstration project 
here in Alaska to fix this dysfunctional system working collaboratively 
with the VA, TriWest, community health centers across the state, 
specialty physicians and hospitals, and the Alaska Primary Care 
Association. It's called the ``Vet Centered Medical Home'' project that 
would return control to the local provider level, increase 
participation from specialists and hospitals, greatly improve referral 
and appointment efficiencies and establish mutually determined 
boundaries and accountabilities to the program so that care 
coordination is greatly improved while unnecessary and costly 
utilization is contained.
    I was so moved by the stories that I heard, and so inspired by the 
ideas coming to me on the way home, that I immediately roughed out the 
basic framework for the demonstration project and shared them with our 
leadership at the Primary Care Association. I hope there is some 
receptivity to these ideas because I do believe very strongly that we 
could move quickly to get this demonstration project developed and 
immediately begin to make things better for our veterans. Perhaps I'm 
naively optimistic, but if we all work together with a ``must do'' 
attitude to come up with a better way of doing things, I feel confident 
that it can be a win-win-win for veterans, providers and the VA system. 
And really, based on what I heard, we have no way to go but up, so why 
not give it a try.
    I'm thanking you in advance for your personal efforts, your 
commitment to our veterans and to thoughtfully receiving my testimony. 
If I or any of our staff can be of assistance to help make a difference 
and resolve many of these issues, we are ready to be at the table and 
do our best to contribute to the solutions. I know that my views are 
shared with many of my colleagues at CHC's across the state and with 
our representatives at the Alaska Primary Care Association.
                                 ______
                                 
          Prepared Statement of John F. Nicely, Anchorage, AK
    Senator, the Choice Program is wrong for Alaska. I needed a simple 
eye exam and called my doctor at the VA. She sent the request to 
``authorizations'' who informed me I needed to contact the Choice Card 
center to get an authorization to get the exam. I called the Choice 
program, which took 30 minutes on hold for them to answer the phone. 
When they came on the phone I was told they had not seen the request 
and for me to call back in 5 to 10 days to get an authorization.
    This is so much hassle just to get an eye exam. In 25 years as a VA 
patient, I have never had so much trouble getting medical care as we 
are experiencing now; and I am not alone, as most all of the members of 
my Disabled American Veterans group are having the same problems 
getting medical care since the Choice Program started.
    Thank you for your time in letting me vent on this problem.
                                 ______
                                 
Prepared Statement of Dana Pictou, Veteran and Clinical Social Worker, 
                             Fairbanks, AK
    My name is Dana Pictou. I am a Veteran and a business owner. I 
provide mental health services to Veteran's and the Fairbanks 
community. I have been in the field for 23 years. I am currently in my 
own private practice with my wife.
    Our clientele right now is mostly veterans in the Fairbanks 
Community. We started seeing Veterans on 5/21/2015. During this period 
the veterans were still tied into the VA system. By the end of June I 
received a notification that all veterans had to use Choice.
    The Choice/TriWest program has been very good for us. They have 
been very efficient and I have been able to get Veterans in very 
quickly. Of course, we had to become a provider for the Choice program 
and that took paper work, tax ID and NPI numbers. That process did not 
take that long and we were accepted and put on the list.
    I have several Veterans who really like the Choice/TriWest and find 
it very helpful. They now have primary care providers which they did 
not have before.
    Communication is a big problem with the VA and Choice/TriWest. I 
have a client who did not change their address with VA to Alaska. So, 
Choice/TriWest was not able to authorize any visit to us. The person 
changed her address with the VA and it took about two and half weeks 
before the address change showed up in the Choice/TriWest program.
    VA, Choice/TriWest do not speak to each other effectively. 
Especially in this modern day of technology. But for the most part, as 
a provider I am very satisfied with the program.
    Second, as a veteran I decided to use the Choice/TriWest program to 
see how long it will take to get an appointment. I called the Choice/
TriWest program to schedule an appointment with an optometrist. I 
called and was put on hold and after about 15 minutes I was able to 
press 1 and have a call back. Approximately, 30 minutes later I 
received the call and told them what I needed and where I wanted to go. 
I was told they would get back to me in about 3 to 5 business days. She 
told me they had to see if my chosen optometrist accepted the program. 
Three days later I received a phone call and was scheduled for the 
appointment where I wanted to go.
    I did have the appointment and was told that the VA only pays $130 
for glasses. Can you tell me where you can go and get prescription 
glasses for $130?
    Again, Choice/TriWest came through without a hitch.
    What I can see from my experience as a provider and as a consumer 
is the program does work. At least it did work for me and was very 
efficient.
    Listening today with the testimonies from other Veterans it seems 
the Major Medical issues are more of a concern. No one spoke about 
mental health care today.
    I do know Choice/TriWest has different departments: medical and 
behavioral health. I believe the behavioral health is working much 
better than the medical.
    As a provider, I stay on top of referrals and make sure I call 
Choice/TriWest to get the veterans in as soon as I can. I believe some 
of these other providers probably need to do the same, especially while 
the VA is going through a major overhaul as it is.
    Here in Fairbanks, there is a very big need for mental health 
providers. By cutting the Choice/TriWest program I would not be able to 
serve this population. This program needs to stay in place, at least 
the behavioral health portion.
                                 ______
                                 
              Prepared Statement of James Pound, Kenai, AK
    First let me take this opportunity to thank you, your staff, Dr. 
Shulkin, and his staff for listening to Alaskan Veteran's. I attended 
the meeting held Monday, July 24, 2015 in Kenai. Obviously the Choice 
program taken from Alaskan ideas is now not working. I would like to 
suggest a review of the basics in the legislative process which may 
resolve the problem.
    Senator Sullivan, your introduction to politics was from the 
administrative side: Attorney General and Commissioner. Both positions 
exposed you to the legislature and the administration at the state 
level. What I believe it may not have exposed you to is the bureaucrats 
that work behind the scenes often advancing their own agenda.
    I have experience in the Administrative Regulation Review process 
and find it amazing how a bureaucrat can interpret statutory language. 
A review of the CFR on the Choice language may provide some answers to 
what went wrong. Language in the Choice Bill ended up being changed in 
the regulatory direction for managing it. I am not indicating that 
anything was done illegally, only that it is a part of the process that 
needs to be constantly reviewed in all administrative departments.
    Since it appears that Dr. Shulkin is interested in fixing the 
problem nationwide, even though he will not grant an exemption for 
Alaska, perhaps the regulation review can be handled internally out of 
his office with guidance and notification to your staff.
    Again thank you for allowing me to submit written testimony on the 
subject of the Veteran's Choice Program.
                                 ______
                                 
             Prepared Statement of Jay Proetto, Haines, AK
    Per conversations with staffers at Senator Sullivan's offices in 
Anchorage and Washington D.C. I am providing the following comments on 
concerns regarding the ill-advised and poorly implemented Veteran's 
Choice Program. I very much appreciate the opportunity to provide input 
and appreciate the opportunity to give the following. I am furnishing 
my contact information so that I may be informed as to the proceedings, 
outcome, and progress in this matter.

    I am John Jay Proetto, a USAF veteran. I served from January 1967 
until January 1971 and received an honorable discharge for this 
service. I was a flight medic and saw action in Viet Nam. I enrolled in 
the VA Medical system in 2004 while a permanent resident of Skagway, 
Alaska. During the time my permanent residence was in Skagway I was 
able to visit the clinic there with authorizations from Integrated Care 
in Anchorage through requests from my primary VA physician at the 
Juneau Clinic. The Skagway Clinic did and does not have a resident 
physician, it is staffed by Nurse Practitioners.
    In July 2014 I moved to Haines and advised VA of the move. They 
then assigned my primary care to the SEARHC Clinic in Haines, where 
there are physicians. I have full confidence in the care I receive at 
this facility. Certain necessary tests and procedures may need to be 
done elsewhere (example: I had to have a test in Anchorage because the 
procedure could not be done closer to my home). This I understand. My 
physician and I work closely with VA Anchorage (Integrated Care) and 
the Juneau VA Clinic to maintain current and proper authorizations. I 
understand my situation is secure until the end of the current fiscal 
year, September 30, 2015.
    It appears that no one directly connected with my medical care 
knows what will happen beyond September 30, 2015. It also appears that 
a reasonably good system in Alaska has been used as a model for changes 
in the VA system nationwide, ironically screwing things up by adding 
unnecessary paperwork, complications, and stress generated by 
uncertainty. I have contacted Integrated Care in Anchorage, the AK 
Veterans' Service Offices in Anchorage, SEARHC in Haines and SEARHC 
Administration in Sitka and Juneau. No one at any of these offices 
knows how ``Veterans Choice'' will affect me in my situation, nor 
thousands of others needing care. This is beyond ridiculous.
    Veterans Choice in response to scandals in the lower 48 states is 
an attempt to give veterans what they should have had all along. It is 
modeled after an Alaska system that Alaska Veterans and veterans 
support organizations fought long and hard for. I am poor, I cannot 
afford to travel. I am happy with my current doctor and the staff at 
SEARHC in Haines, Alaska.
                                 ______
                                 
         Telephone Statement from Samuel Senner, Anchorage, AK
    [Mr. Samuel Senner called the Washington, DC, office regarding his 
experience with the Choice Program. Mr. Senner stated that he would be 
glad to speak with someone from the office or provide any advice that 
would be helpful during the anticipated reworking of the program.]
    Call regarding VA Choice Program: Disabled veteran issues with 
Choice Program. Spoke at length in person with Rep. Mia Costello. Knee 
surgery and had total knee replacement recently, which led to lower 
back pain. He spoke with Choice and was authorized to see a 
chiropractor. The Choice representative was authorized to schedule it 
and would contact him after 4 days. After 1.5 weeks of no response, he 
called back and spoke with another Choice rep who stated that his 
authorization was in the system, there were no problems, and told him 
to schedule the appointment and everything would be taken care of.
    Mr. Senner made the appointment, but heard nothing. Fortunately, he 
landed a great doctor who said he'd help regardless of the VA's 
response. After no response from VA after another 1.5 weeks, Mr. Senner 
called and spoke with supervisor, April Gray (Grey?). Same story: very 
nice and promised a lot, but nothing in response.
    He never received a Choice Card (promised by several reps) and 
never received call back from Choice reps.
    After 2 months since the initial contact with Choice Program, his 
doctor found his approval in the system, but he had never been 
contacted by the VA to let him know that his request had been approved. 
Never once received a call back from Choice.
    Mr. Senner stated that the Choice reps are wonderful on the phone, 
but never actually responded or held up on their promises.
    He was offered to speak with someone from their office on this 
issue, or offer advice as needed.
                                 ______
                                 
        Prepared Statement of Glenn Shields, Delta Junction, AK
    As a veteran who served over 20 years in the army, I would like to 
add my comment on the VA. I've lived in Alaska for many years and have 
received treatment from the VA.
    I recently needed to get refills on some of my medication, and I've 
never had any trouble at the Fairbanks VA clinic before, however now I 
was refused and told that I had to get my meds from the clinic where I 
had been getting them due to a recent change.
    I think that a veteran should be able to get medicine at any VA 
hospital or clinic. I'm not happy with the VA Choice Program.
                                 ______
                                 
        Prepared Statement of Richard L. Stevenson, Wasilla, AK
    My experience to date on the VA choice medical program for outside 
medical needs.
    The first reason given for choice medical card was, it was for any 
VA patient 40 miles or more from a VA hospital or medical center, to go 
to a private provider outside the VA which I qualified. Notification to 
the VA was still required. No notification was given to VA patients on 
the new program ``choice'' that you now had to call the choice phone 
number to receive VA medical attention from a medical doctor outside 
the VA I was half way through heart testing, when I was told I would 
have to wait until the Choice Program authorized my testing already 
approved by the VA I had no idea what they were talking about. I was 
already three years overdue, now I had to wait 14 more days for the 
choice program to kick in. No one knew anything about the Choice 
Program--not patients, VA personnel, nor private vendors. Only after a 
meeting at the Menard Sports Center with the VA director did I know 
what was going on. At the VA, the staff still did not know what to say 
to the VA patients, just that you had to call the number on the card. 
No notification, no training for VA staff, it was bad. Even when you 
called the Choice number on the TRI-West or Choice operators were not 
sure of what procedures to follow. There was a big disconnect between 
the VA and Choice people.
    This system is not working for the VA patient. For instance, this 
is the way I understand a request to see an outside doctor VA patient 
asked to see, five days their VA provider for a medical need. The P.A. 
checks out the issues, they have to put a request in for a specialist, 
this is sent to the VA integrative care unit. This can take up to 7 
days to be seen by an R.N. for approval. Integrative care calls VA 
patients, tells them to call the VA Choice Program. You call, the 
Choice Rep's go through 15 to 20 minutes asking questions they should 
already have. If the rep. knows what to do they will not transfer the 
VA patient. My experience is that three out of seven times I was 
helped, it took 9 more days before the Choice agent got back to me with 
an appointment. That is 21 days that went by to just get an 
appointment. It can be longer that you have to wait for the 
appointment. This is two times the VA would take. That is bad. Another 
issue I have come across was that the doctors I had been seeing for my 
conditions will not sign up to the Choice Program. So far three doctors 
the VA has sent me to are not and will not be part of the Choice 
Program. The Alaskan Heart Institute finally did sign, but they didn't 
at first.
    As a veteran, using the VA, I do not see how the VA Choice Program 
can be a proactive move for their health. The VA is hard enough to 
understand and work with. Now the Choice Program is not about our 
health, but financial management. Please fix the VA system, do not add 
more road blocks.
                                 ______
                                 
   Prepared Statement of Aaron Swain, Case Manager, Adult Behavioral 
                      Health, Kenai Peninsula, AK
    My name is Aaron Swain. I'm a United States Navy Veteran, I come 
from a service family, and my brothers and I chose to serve. We have 
gone through screenings, assessments, and programs to receive benefits.
    Speaking from my own experience, the Veteran's Choice program is 
one of the best changes to the VA/VB system since I enrolled in 2008. 
It took 5 years for me to get into see a provider, and then the 
services were only available if I booked months in advance. I worked 
with coordinators and representatives to get what little services I 
can. The Choice program reduced my wait time from almost a year to just 
over 3 weeks. With the introduction of another limitation, mandating 
that all our services go through specific providers, this is going to 
increase our wait times and reduce the efficacy of services. Veterans 
served their time, how does it make sense to make them wait longer?
    I'm an Alaskan by birth. I was born in Soldotna, raised in 
Sterling, graduated from University of Alaska Anchorage through an 
extension site at the Kenai River Campus, and live on the Peninsula. I 
work for a community mental health clinic and I buy local before I go 
to a franchise. I've lived here my entire life and my experience with 
Native Corporations has shown me that they are not about equality, 
which Veterans fought, bled, cried, and died for, but rather for 
entitlement. Natives will have preferential treatment at these 
facilities because that is their purpose, as a way to restitute the 
domination and removal of their culture. This means that non-Native 
Veterans will have to wait until there is an availability for them to 
be seen. Like I said before, we did our time and paid our dues. So, why 
do we have to wait to be taken care of now?
    The Choice Program, is about CHOICE. I chose my optometrists, my 
councilors, and my primary care physician. I found the services I 
needed through providers I trusted while maintaining a limit on the 
amount I cost my fellow tax payers. I find my therapeutic relationship 
with my providers to be more important that the services they provide. 
Saying that I can only receive services from a specific hospital is not 
a progression in treatment, but a regression in systems--back to when 
Veterans were bussed from the Kenai Peninsula to Anchorage to go to 
specified providers. This was expensive, time intensive, and did not 
meet the needs of the Veterans. These providers have a policy to bump 
non-Natives from services for their target population. They receive 
grants and incentives to do this. This does not promote Choice, 
recovery, or a sense that the system is going to be helpful.
    In summary--I have waited long enough for my services. I have 
jumped through hoops and stood in line. By saying I have to go to a 
hospital with a racial bias before I can see a doctor tells me you want 
me to wait longer. This is not a choice. This is a restriction.
                                 ______
                                 
                    Prepared Statement of Jan Trojan
    As an Alaska rural health specialist (a volunteer) I have already 
received numerous complaints on the veterans Choice card. Mostly, that 
services preapproved have been denied. As I understand the process 10 
million dollars were removed from Alaska Veterans Health system to be 
put in the veterans Choice card.
    Susan Yeager had fixed Alaska! She was the director of the Alaska 
VHA. This took 10 million dollars entitled to health care for the 
Alaska veterans and placed it into a new program. Advertising, 
administration, and equipment was then used with veteran health care 
funds, only to confuse and deny veterans medical care. I have given my 
documentation to Senator Murkowski's office. Denial letters to include 
my own.
    Alaska is the last frontier and when the Alaska VA fixed our system 
this new improved system only wasted money that was supposed to go to 
the veterans as health care not another layer of bureaucracy.
                                 ______
                                 
 Prepared Statement of Susan Williams, representing a female veteran, 
                              Chugiak, AK
Concerns:
     She was told by Choice Staff on the phone that urgent 
requests are not dealt with quickly.
     TriWest only down loads referrals once a week I was told 
by staff at Choice.
     Because of the slow action for her Physical therapy to be 
scheduled she is not recovering and this affects her and her family.
     This testimony was submitted to Sen. Sullivan's public 
testimony site with her permission.
                                 ______
                                 
      Prepared Statement of David S. Zumbro, M.D., Alaska Retinal 
                       Consultants, Anchorage, AK
    This letter is to describe how the implementation of Veteran's 
Choice affected the delivery of retinal care in Alaska.
    We are the only retina specialty group in the state of Alaska. We 
diagnose and treat several common retinal diseases to include age-
related macular degeneration, diabetic retinopathy, retinal 
detachments, and eye trauma. No other optometry group or ophthalmology 
group in the state is qualified to treat these conditions as we do. 
Patients that require treatment for such retinal problems either see us 
or have to travel out of state.
    When Veteran's Choice was abruptly implemented, the ensuing 
confusion and chaos necessitated us canceling at least half a dozen 
planned surgical procedures and multiple clinic visits. It has also 
resulted in one of our employees dedicating the majority of her time 
during the day simply helping our veterans navigate the confusing 
bureaucratic morass known as ``Veteran's Choice.''
    It seems logical that a program designed to help veterans get 
access to medical care should be implemented only when it actually does 
what the administrators promise. It is the confusing bureaucracy that 
interferes with veteran's access to retinal care, not the conduct of my 
practice. In fact, as a retired Colonel in the U.S. Army, taking care 
of our Nation's heroes is one of my passions. I suggest that in the 
future when the VA leadership initiates similar programs, they do so 
with more transparency and less abruptly. Otherwise, veterans suffer 
needlessly. The VA leadership also needs to quit patting themselves on 
the back until this program works as promised.
      

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